What should an occupational therapy note include?
An OT (occupational therapy) note records what the client wants to achieve, what you observed in function and activity, your assessment against goals, and the plan. OTs also write longer assessment reports for schools, schemes and employers. HeroMed's AI Scribe drafts the session note, generates reports and letters from the record, and prepares the invoice in one click.
Written by the HeroMed team · Last reviewed 3 October 2026
An OT (occupational therapy) note records what the client wants to achieve, what you observed in function and activity, your assessment against goals, and the plan. OTs also write longer assessment reports for schools, schemes and employers. HeroMed's AI Scribe drafts the session note, generates reports and letters from the record, and prepares the invoice in one click.
The full guide has a template, a worked example and the HPCSA Booklet 9 record-keeping rules: OT and Occupational Therapy Notes South Africa.