AI SOAP Notes for Occupational Therapy

Automate your OT documentation. Save hours every week with AI-powered clinical notes that understand ADLs, functional goals, sensory processing, and occupation-based interventions.

Try Free for 3 Days
  • Works with NetHealth, WebPT, and any EHR
  • HIPAA compliant
  • $49/month
HIPAA Compliant
PHI Auto-Removed
Works With Any EHR
Cancel Anytime

Occupational Therapy Documentation Challenges

If you're an OT or COTA, you understand the complexity. Documenting ADL performance, sensory processing observations, fine motor skills, and occupation-based interventions takes detailed notes. Add in the need to tie everything back to meaningful functional goals, and you're spending hours after work catching up. It doesn't have to be this way.

Without SOAP Note Buddy

  • Hours documenting detailed ADL performance levels
  • Writing unique sensory processing observations for each session
  • Struggling to connect interventions to occupation-based goals
  • Copy-pasting between patients and risking documentation errors

With SOAP Note Buddy

  • Generate complete OT notes in seconds
  • AI writes detailed, patient-specific ADL documentation
  • Automatically connects interventions to functional goals
  • Each note is unique and clinically appropriate

How It Works for Occupational Therapy

1

Add Your Patient

Enter the patient's evaluation summary - diagnosis, occupational profile, functional goals, and intervention approaches. This is stored locally on your device (never on our servers).

2

Open Your EHR

Navigate to NetHealth, WebPT, Clinicient, TherapySource, or any web-based OT system. SOAP Note Buddy automatically detects the documentation fields.

3

Click Generate

One click generates personalized SOAP notes based on your patient's specific ADL goals, sensory needs, fine motor skills, and occupation-based interventions.

4

Review & Submit

Review the AI-generated content, make any needed adjustments, and submit. Documentation that used to take 20+ minutes now takes 2-3.

Features for Occupational Therapy

OT-Specific Templates

Customizable templates for daily notes, progress notes, evaluations, re-evaluations, and discharge summaries. Understands OT terminology, ADL levels, and occupation-based documentation.

Works With NetHealth, WebPT & More

Automatically detects and fills fields in NetHealth, WebPT, Clinicient, TherapySource, and any other browser-based EHR system.

HIPAA Compliant

PHI is automatically removed before AI processing. Patient names, DOBs, and identifiers never leave your device.

Save 10+ Hours/Week

OT documentation that used to take hours now takes minutes. More time for patient care, less time charting after hours.

Goal-Aware AI

Understands that Goal 1 (dressing) is different from Goal 2 (meal prep). Writes unique, appropriate progress notes for each occupation-based goal based on your eval context.

Understands OT Terminology

ADLs, IADLs, fine motor, gross motor, sensory processing, hand therapy, cognition, visual-perceptual skills - the AI speaks your language.

Occupational Therapy SOAP Note Example

Daily Note: CVA - Upper Extremity and ADL Retraining

Scenario: 72-year-old patient, 3 weeks post left CVA with right hemiparesis. Working on right UE function, dressing, and grooming independence.

S - Subjective

Patient reports "my arm feels a little stronger today" and states she was able to brush her teeth with minimal help from her daughter this morning. Rates frustration level at 4/10 (down from 6/10 last visit). Patient expresses motivation to return to cooking simple meals independently. Denies any new pain or concerns.

O - Objective

UE Function: R shoulder flexion AROM 95 degrees (from 85 degrees last visit), R grip strength 12 lbs (improved from 8 lbs). Mild spasticity noted in R wrist/finger flexors (MAS 1+).
ADL Performance: Donning front-closure bra with mod A for fastening (improved from max A). Upper body dressing with min A for R sleeve management. Grooming (toothbrushing, hairbrushing) with setup and supervision.
Treatment: AROM/PROM R UE, grip strengthening with therapy putty, task-specific training for one-handed dressing techniques, grooming activity with adaptive equipment (built-up handle toothbrush), neuromuscular re-education for R hand manipulation.
Cognition: Follows 2-step commands, able to sequence dressing tasks with verbal cueing.

A - Assessment

Patient is making functional progress toward ADL independence goals. R UE strength and AROM improved since last visit. Patient demonstrating improved ability to incorporate R UE as assist during bilateral tasks. One-handed techniques reducing need for physical assistance. Continues to require skilled OT for UE strengthening, neuromuscular re-education, and ADL training to achieve safe independence in self-care activities.

P - Plan

Continue OT 3x/week for UE strengthening, fine motor coordination, and ADL training. Next visit: progress to bilateral coordination activities, introduce light meal prep task (making sandwich). Continue adaptive equipment training. Patient education on home exercise program for R UE and energy conservation techniques. Coordinate with PT for transfer and mobility carryover.

This example was generated by SOAP Note Buddy in under 10 seconds.

Works in Any OT Setting

Whether you work in outpatient, inpatient rehab, home health, pediatrics, or skilled nursing, SOAP Note Buddy adapts to your documentation needs.

Outpatient OT

High-volume clinics with tight schedules. Generate notes between patients for hand therapy, ortho, neuro, and general OT cases.

Inpatient Rehab

Acute rehab documentation with complex ADL training, cognition, and functional goals. AI understands FIM levels and rehab terminology.

Home Health

Document in the car or at home after visits. Capture IADL training, home safety assessments, and caregiver education.

Pediatric OT

Sensory processing, fine motor, handwriting, and self-care skills. AI understands developmental milestones and school-based documentation.

Skilled Nursing

SNF-specific requirements for Medicare documentation. AI understands skilled vs. maintenance therapy for ADL training.

Hand Therapy

Specialized documentation for hand injuries, post-surgical rehab, and orthopedic conditions. Understands splinting, tendon protocols, and functional outcomes.

Simple, Affordable Pricing

No contracts. No setup fees. Cancel anytime.

Monthly Price $49/month
Free Trial 3 days
EHR Support Any web-based
Credit Card Required Yes, for trial
Compare Our Pricing

Most AI scribes charge $99-$299/month. SOAP Note Buddy is $49/month with no contracts. That's $600+/year in savings. One less patient per day at your billing rate pays for it.

Ready to Save Hours on OT Documentation?

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Occupational Therapy FAQ

Does SOAP Note Buddy work with NetHealth?

Yes! SOAP Note Buddy works with NetHealth, WebPT, Clinicient, TherapySource, and any other browser-based EHR. It automatically detects fields and fills them with AI-generated content.

Is the AI trained on occupational therapy documentation?

Yes. SOAP Note Buddy understands OT-specific terminology including ADL/IADL levels, fine motor skills, sensory processing, cognition, visual-perceptual skills, and occupation-based goal writing. It generates clinically appropriate content based on your patient's evaluation summary.

Does it work for hand therapy documentation?

Absolutely. The AI understands hand therapy terminology including tendon protocols, splinting, grip/pinch strength, ROM measurements, and functional outcomes. Great for CHTs and OTs specializing in upper extremity rehab.

How does SOAP Note Buddy protect patient information?

PHI is automatically scrubbed before any data is sent to AI processing. Patient names, DOBs, addresses, and other identifiers are removed locally on your device. We're HIPAA compliant and offer a Business Associate Agreement (BAA).

How much time will I actually save?

Most OTs report saving 10-15 hours per week on documentation. Daily notes that took 20+ minutes now take 2-3 minutes. That's 15-20 minutes saved per patient.

Can I customize the templates for my practice?

Yes. You can customize how each SOAP section generates - add specific instructions for subjective, objective, assessment, and plan sections. The AI follows your preferences for ADL documentation style, intervention terminology, and goal language.

Does it work for COTAs too?

Absolutely. SOAP Note Buddy is used by both OTs and COTAs. The AI understands the documentation requirements for daily treatment notes and can adapt to your specific workflow and supervision requirements.

Is there a free trial?

Yes! 3-day free trial. A credit card is required but you won't be charged if you cancel within 3 days. No pressure, no sales calls.