Use Claude Pro for Long OT Evaluation Reports

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:

• Background: Diagnosis, referral reason, date of onset, prior level of function, living situation
• Assessment scores: List tool names and scores/results
• Functional observations: What you observed in ADLs, IADLs, mobility, cognition
• Patient goals: What the patient/family said they want to achieve
• Your recommendations: Frequency, duration, specific interventions planned

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:

• Infer details that weren't in your notes (correct them)
• Soften language that needs to be more specific
• Use slightly different assessment terminology than your facility prefers

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:

1. Select all the report text (Ctrl+A or click and drag)
2. Copy (Ctrl+C)
3. Paste into your EMR's evaluation note fields

Most OTs paste the narrative sections and then manually enter the structured data (assessment scores, CPT codes) into the EMR's specific data fields.