Custom OT Documentation Assistant: Build Your Personal AI That Knows Your Practice

What This Builds

Instead of re-explaining your clinical setting every time you open Claude, a Claude Project is a persistent AI assistant that already knows everything about your practice: your setting, your common diagnoses, your documentation formats, your employer's requirements, and your professional style. Every conversation starts with full context already loaded — you just paste your session notes and get documentation back, every time, without setup. OTs who build this save an additional 5–10 minutes per session compared to using generic Claude, and produce more consistent, setting-appropriate documentation.

Prerequisites

• Claude Pro subscription ($20/month at claude.ai) — Projects require Claude Pro
• Comfortable using Claude for at least 2 weeks for basic documentation tasks
• 60–90 minutes to build and test your project

The Concept

A Claude Project is like a specialized coworker who has read your employee handbook, your most common patient cases, your clinical guidelines, and your documentation policy — and is available every time you need them. Unlike a regular chat where you start from scratch, a Project carries persistent "instructions" (called a System Prompt) that load automatically every time you start a new conversation within that project. Think of it as programming your own documentation assistant with your specific clinical knowledge.

Build It Step by Step

Part 1: Access Claude Projects

1. Log in to claude.ai with your Pro account
2. In the left sidebar, look for Projects and click New Project
3. Give it a name: "OT Documentation — [Your Setting]" (e.g., "OT Documentation — Outpatient Hand Therapy")

What you should see: A project workspace with a large text field labeled "Project Instructions" or similar.

Part 2: Write your Project Instructions (System Prompt)

This is the core of your assistant. Copy the template below into the Project Instructions field, then customize every section in brackets:

You are a documentation assistant for a licensed occupational therapist (OTR/L). Help draft clinical documentation that is professional, accurate, and appropriate for insurance and medical record purposes.

## My Clinical Setting
Setting type: [outpatient hand therapy / acute care hospital / school district / SNF / home health]
Employer: [clinic name or setting type, e.g., "private outpatient practice" or "large hospital system"]
State of practice: [your state]

## My Patient Population
Primary diagnoses I treat: [list your 5-8 most common diagnoses]
Typical patient demographics: [e.g., "mostly Medicare-age adults" or "pediatric 3-12 years" or "adults post upper extremity surgery"]
Average caseload: [X patients per day]

## Documentation Format
Progress note format: [SOAP / DAP / narrative paragraph]
Evaluation report format: [structured vs. narrative]
IEP format (if school-based): [your district's goal format]

## EMR System
My EMR: [Epic / Net Health / WebPT / PointClickCare / Frontline]
Character limits I need to be aware of: [if your EMR has text field limits, note them]

## Insurance/Payer Context
Primary payers: [Medicare Part B, Medicaid, Blue Cross, etc.]
Prior auth requirements I deal with most: [common auth situations]

## My Documentation Standards
- Always write in third person objective clinical language
- Always include specific, measurable data (% accuracy, levels of assistance, degrees of motion, verbal cues required)
- Medical necessity language for insurance: always justify WHY skilled OT is required, not just what was done
- Avoid vague language: "patient is improving" → "patient demonstrated improved shoulder AROM from 85° to 110° flexion over the past 3 sessions"
- For school OT: always connect deficits to educational impact and classroom participation

## HIPAA Instructions
CRITICAL: Never include real patient names, dates of birth, or identifying information. Use [patient] as placeholder for all patient references. I will replace [patient] with real names before submitting documentation.

## Response Format
When I give you session notes, produce:
1. Complete formatted note (SOAP/DAP/narrative) ready to paste into my EMR
2. Any specific notes about what I should verify before submitting (flag anything that seems incomplete)
3. If I need a prior auth, include the specific medical necessity language for my common payers

## My Common Documentation Challenges
[List 2-3 documentation situations you find difficult, so Claude can be extra helpful in those areas. For example: "I struggle with writing strong functional justification for continued OT," or "I need help connecting pediatric fine motor deficits to classroom impact."]

Fill in every section and save the project.

Part 3: Add Knowledge Files (Claude Pro feature)

If you have documents that should inform your assistant's responses, upload them to the project:

1. Click Add content in the project sidebar
2. Upload relevant documents:

   • Your facility's documentation policy (if you have it as a PDF)
   • Common IEP goal templates from your district
   • A prior authorization criteria document for your main payer
   • Examples of your best-written notes (remove patient info first)

Claude will reference these documents automatically when relevant.

Part 4: Test and Refine

Test with three representative documentation scenarios from your actual caseload:

Test 1 — Basic progress note: Paste bullet notes from a typical session. Verify the output matches your EMR format and clinical standards.

Test 2 — Prior authorization: Request a prior auth letter. Verify it includes appropriate medical necessity language for your specific payer.

Test 3 — Complex situation: Try your hardest documentation challenge — the type of note or letter that always takes you the longest. See how the assistant handles it.

For each test, note what's wrong and update the project instructions to fix it. Refine 2–3 times until the output consistently meets your standards.

Real Example: Outpatient Hand Therapy OT

Setup: Project configured for outpatient hand therapy. Common diagnoses: distal radius fracture, trigger finger, CTS, lateral epicondylitis, Dupuytren's. EMR: Net Health. Insurance: Medicare Part B, BCBS, Aetna.

Input: Paste after a session:

Trigger finger release surgery left ring finger 3 weeks post-op. Wound healing well, no signs infection. Passive ROM PIPJ 0-95 degrees. Active ROM PIPJ 0-70 degrees (goal 0-90). Performed place-hold tendon gliding, intrinsic stretching, scar massage. Patient performing HEP 3x daily per report. Pain 2/10 during exercises.

Output from project: A complete Net Health-format SOAP note with:

• Specific ROM measurements referenced against goals
• Skilled therapy justification (skilled care required for post-surgical wound management and ROM restoration)
• Plan for next session
• Flag: "Verify that the 'place-hold' technique is documented as skilled instruction, not just patient performance"

Time saved: What used to take 12–15 minutes in the EMR now takes 2 minutes to paste, review, and copy.

What to Do When It Breaks

• Output is in wrong format → Update the project instructions under "Documentation Format" to be more specific; paste an example note in the preferred format
• Assistant uses vague language → Add to instructions: "NEVER use: 'patient is improving,' 'progressing well,' 'tolerating treatment well.' Replace with specific measurable data."
• Prior auth language is too generic → Upload your payer's actual coverage criteria document as a knowledge file; Claude will reference the specific criteria
• Output is too long for your EMR → Add to instructions: "Keep progress notes under [X] characters to fit my EMR's text fields"

Variations

• Simpler version: If you don't need the full Project feature, save your refined system prompt as a text file and paste it at the start of every new Claude conversation — same effect, no Pro subscription required
• Extended version: Add separate sections in the project for school-based documentation (IEP season) vs. clinical documentation (SNF Medicare) if you work across settings

What to Do Next

• This week: Build the project, run 3 test scenarios, refine the instructions
• This month: Use the project for all your documentation for 30 days; note where it still needs refinement
• Advanced: Once the project works well for you, consider building a separate version for your supervising COTA so they can generate their own session notes more efficiently

Advanced guide for occupational therapist professionals. Claude Projects requires a Claude Pro subscription ($20/month).