Occupational therapy report template (free, with guidance)

A paediatric occupational therapy report should say why the child was seen, what you did, what you found, what it means for daily life, and what should happen next. The template below covers those points in nine sections and works for most assessment reports in Australian clinics. Copy it, delete what does not apply, and adapt the headings to your clinic's style.

What an occupational therapy report must include

No single format is required for a paediatric OT assessment report, but the Shared Code of conduct that applies to occupational therapists sets clear expectations for anything you sign. Records should be accurate, current, factual, objective and legible to other practitioners. Reports should be honest and not misleading, and you should sign only documents you believe are accurate, taking reasonable steps to verify the content and not leaving out relevant information. You should also stay within the limits of your knowledge when giving an opinion.

In practice, a useful report covers:

• Who and why. The child, their guardians, who referred them, and the questions the report is meant to answer.
• Background. Developmental, medical, educational and family context, with parent-reported information marked as such.
• How you assessed. Each standardised tool (name and edition), each clinical observation, where it took place, and anything that departed from standard administration.
• What you found. Results as the test manual reports them, and a plain description of how the child performs in play, self-care, learning, movement and regulation.
• What it means. Your clinical interpretation, and what remains uncertain.
• What should happen next. Specific recommendations, goals agreed with the family, and a review point.
• Consent and sign-off. Who agreed to the report being shared, with whom, and your name, qualifications, registration details and signature.

OT is a regulated profession, so check the Occupational Therapy Board of Australia's codes and guidelines page for current requirements on records, telehealth and advertising.

The template

Paste this into your document and replace each bracketed prompt with your own content.

1. Identifying details

[Child's name] [Date of birth] [Guardian name(s)] [Referrer and date of referral] [Assessment date(s) and location] [Clinician name, qualifications, registration details]

2. Reason for referral

[Who referred and why, in one or two sentences] [Family's concerns, in their words where possible] [Questions this report needs to answer]

3. Background and history

[Birth, developmental and medical history relevant to this referral] [Education and care setting, and what teachers or educators have noticed] [Previous therapy or reports] [Mark each item as parent-reported, school-reported or from records]

4. Assessment methods

[Standardised tools: name, edition, date administered] [Clinical observations: setting, duration, who was present] [Parent, teacher or child questionnaires used] [Any deviations from standard administration and why]

5. Results

[Scores as the manual reports them, with the norms used] [Fine motor, visual motor, self-care, sensory processing and regulation, play, handwriting or school tasks, as relevant] [A plain description of what the child did, separate from your interpretation]

6. Clinical impressions

[What the findings mean for [child's name]'s participation at home, school and in the community] [Strengths as well as difficulties] [Diagnostic framework used, if any, and what is still uncertain]

7. Recommendations

[Each recommendation: what, who provides it, how often, where, for how long] [Equipment, environmental changes or classroom strategies] [Referrals to other professionals] [Review date]

8. Goals

[Two to four functional, measurable goals agreed with the family] [How progress will be measured]

9. Consent and sign-off

[Consent to share, and the recipients named] [Clinician name, qualifications, registration details] [Signature and date]

Writing tips for families, schools and NDIS readers

One report is often read by a parent, a teacher, a paediatrician and a funding planner. Write so each of them can find what they need.

• Lead with a short summary. Two or three plain sentences at the top that a parent can read first and a planner can scan.
• Keep observation and interpretation apart. "[Child's name] needed adult prompting to fasten buttons on four of five attempts" is an observation. "Fine motor difficulty" is an interpretation. Readers trust the second more when they can see the first.
• Describe function, not just scores. A standard score means little to a teacher. Say what it looks like at a desk, at lunch or getting dressed.
• Be specific in recommendations. "Occupational therapy" is not a recommendation. State the focus, how often, in which setting, and what you expect to change by the review date.
• Name the strengths. Families read these reports closely, and strengths help schools plan.
• Explain jargon once. If you use "praxis", "proprioception" or "interoception", define it in a sentence.
• Say what you did not assess. A report that states its limits is easier to rely on.
• Check who the reader is. Reports for funding bodies often need more detail on frequency, duration and the link between a support and the child's goals. Check the requirements of whoever will read it, rather than assuming.

Common mistakes

• Copying forward old content. Text carried over from a previous report can describe a child who no longer exists. Re-read every line against the current assessment.
• Mixing parent report with clinical observation. Label the source of each statement.
• Reporting scores without context. Give the tool, edition, norms and any limits on the result.
• Vague recommendations. If a reader cannot tell what to do on Monday, the recommendation needs more detail.
• Opinions beyond your evidence. Stay within what you assessed and what your training supports. Refer on where needed.
• Unclear consent. Record who agreed to the report going where, and share it only with those people.
• Deficit-only language. Describe the child's participation and what supports it, not just what they cannot do.
• Unsigned or late reports. Complete the report within a reasonable time and sign only when you are satisfied it is accurate.

Where Syntropic Health fits

Syntropic Health drafts reports like this from the whole case, in your clinic's template; the clinician reviews and signs. See clinical reports.

Sources

• ahpra.gov.au
• occupationaltherapyboard.gov.au
• occupationaltherapyboard.gov.au