For Occupational Therapists ·
What you'll accomplish
By the end of this guide, you'll be able to paste your evaluation notes into Claude and receive a complete, professionally written OT evaluation report — occupational profile, assessment interpretation, functional implications, goals, and plan — in under 3 minutes. For reports that currently take 45–90 minutes, this is a transformative time save.
What you'll need
Go to claude.ai and open a new conversation. Before pasting your notes, set the context with a brief instruction:
You are helping an occupational therapist write clinical documentation. I will give you evaluation notes in bullet-point or rough form. Please convert them into a complete OT evaluation report using professional clinical language appropriate for insurance and medical record documentation. Always use [patient] as a placeholder — never include real names.
Format:
1. Reason for Referral
2. Occupational Profile (background, prior level, patient-stated goals)
3. Assessment Results (organized by domain)
4. Functional Implications
5. Goals (long-term and short-term, measurable)
6. Plan (frequency, duration, interventions)
7. Therapist attestation placeholder
Claude will confirm it's ready.
The better-organized your input, the better the output. Take 2–3 minutes to organize your handwritten or voice notes into these rough categories before pasting:
You don't need perfect sentences — bullet points work. Claude converts them.
In the same conversation (context already set), paste:
Here are my evaluation notes. Please write the full evaluation report:
BACKGROUND:
- [Your background notes here]
ASSESSMENTS:
- [Assessment names and scores]
FUNCTIONAL OBSERVATIONS:
- [What you observed]
PATIENT GOALS:
- [What they told you they want to accomplish]
MY CLINICAL RECOMMENDATIONS:
- [Your frequency, duration, interventions]
Press Enter. Claude will produce the complete report, typically 400–700 words.
Read the entire report before using it. Clinical documentation is your professional responsibility — Claude may:
Edit directly in Claude by following up: "In the Assessment Results section, make the UE motor findings more specific — focus on the implications for dressing and bathing tasks." Claude refines the section you indicate.
Once the report is accurate and complete:
Most OTs paste the narrative sections and then manually enter the structured data (assessment scores, CPT codes) into the EMR's specific data fields.
School OT evaluation:
Write an OT evaluation report for school-based services. [Student] is a [grade] student referred for [reason]. Assessment data: [list]. Classroom observations: [describe]. Eligibility determination: [services needed or not]. Recommended goals: [areas].
SNF initial evaluation:
Write an OT evaluation for a skilled nursing facility admission. [Patient] admitted after [event]. Prior level: []. Assessment results: [FIM scores, cognitive screening]. Current ADL status: []. Skilled OT need: [justify why skilled care is required, not maintenance].
Home health evaluation:
Write an OT home health evaluation. [Patient] referred post [event]. Home environment: [describe]. ADL status: []. Safety concerns identified: [list]. Recommended: [frequency, interventions, home modifications].