OT and Occupational Therapy Notes South Africa: SOAP Notes, Assessment Reports and AI Documentation

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.

HeroMed is South African practice software with an AI Scribe built in. For OTs and occupational therapists, it drafts the SOAP plus functional assessment note during the session, keeps it in the patient record, and turns the signed note into documents, the invoice and the scheme claim.

The SOAP plus functional assessment structure

Assessment reports usually add: reason for referral, background, tests used, results, interpretation and recommendations.

Example note

This is a made-up example for illustration, not a real patient.

S: Parent reports the 7-year-old is struggling to finish written work in class. O: Immature pencil grip, letters inconsistent in size, tires after five minutes of writing. Sits with rounded posture. A: Fine motor and postural control below age level, affecting written work. Small improvement in grip since last month. P: Grip and core strength activities, slanted writing board, home programme sent to parent, note to teacher. Review in two weeks.

Writing reports faster

Reports to schools, medical schemes and employers take OTs hours. In HeroMed, the AI can draft a report or letter from the signed session notes, which you then edit and sign.

HPCSA Booklet 9 and POPIA: record-keeping for OTs and occupational therapists

The HPCSA's Guidelines on the Keeping of Patient Health Records (Booklet 9, revised September 2022) apply to every registered practitioner. In plain terms:

• What a record must contain (section 3.2). The patient's identifying details, a full history including allergies, the time, date and place of each consultation, your assessment, the proposed management, medication and dosage, referrals, the patient's response to treatment, investigations and results, time booked off work and why, and written proof of informed consent where relevant.
• Write it at the time (section 4.1). Notes are made during or as soon as possible after each interaction. Late entries are marked as late, with the reason.
• Make it clear and attributable (sections 4.2 and 4.3). Records must be accurate, legible and free of unclear abbreviations, and every entry must show who made it. Allergies and special needs should be easy to see (section 4.4).
• Changes are recorded, not hidden (section 5). Late and extra entries are dated and signed (electronically for digital records), and the reason for any change or correction is written on the record. Records may not be tampered with.
• Keep it secure (section 6). Only authorised people may access records, whether on paper or electronic.
• How long to keep it (section 7). At least six years from the patient's last treatment. For patients treated as minors, at least until their 21st birthday. For mentally incapacitated patients, for their lifetime. Records under the Occupational Health and Safety Act, 20 years after treatment.
• Patient access (section 9). Anyone aged 12 or older may ask for a copy of their own records. For a patient under 16, a parent or guardian may apply, but access needs the patient's written authorisation.

Under POPIA, health information is special personal information. You need a lawful reason to process it, consent where it applies, reasonable security (passwords, user permissions, backups) and a way to report breaches.

HeroMed keeps every signed note in the patient record with a date, an author and a history of changes, and access is controlled per user. This is general guidance, not legal advice. Read the official Booklet 9 on the HPCSA site and speak to your professional body if you're unsure.

From note to invoice in HeroMed

1. Patient snapshot. Before the patient sits down, HeroMed's AI summarises their history from the record, so you start the session already knowing what happened last time.
2. AI Scribe drafts the note. With the patient's consent, the AI Scribe listens to the session and drafts the note in the structure above, using a built-in template or one you set up for your practice. You review, edit and sign.
3. Documents and Ask AI. From the signed note you can generate referral letters, reports and sick notes, and ask the AI questions about the patient's notes.
4. One-click billing. The signed note prepares the invoice and the medical scheme claim in one click, with no copying into another system.

For OTs and occupational therapists, that means the note you sign is also the start of your billing, your letters and your next booking.

Checklist before you sign a note

• Date, time and your name are on the note
• Patient's own words are recorded where they matter
• Findings are measurable and comparable with last time
• Assessment explains your reasoning
• Plan includes follow-up and any referral
• Consent is recorded where needed
• You reviewed the AI draft before signing

Related reading

• SOAP notes in South Africa: HPCSA Booklet 9 guide
• OT practice software in South Africa
• Best occupational therapy software in South Africa
• HeroMed AI Scribe