Upcoming Webinars 


The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Log in

Log in

Massachusetts OT Documentation

Documentation Responsibilities

The occupational therapist’s primary role in documentation is to ensure that documentation is completed timely, following formats and standards established by the practice setting, agencies, external accreditation programs, state and federal law, and other regulators and payers. The occupational therapist’s primary role is to document the following, with input from the occupational therapy assistant, as applicable:

    • Screenings;
    • Evaluations;
    • Initial goals and any modifications in goals, as needed;
    • Initial intervention plans and any modifications;
    • Patient progress notes;
    • Formal reviews of the initial intervention plan (or reevaluations); and
    • Discharge evaluations or summaries.

Powered by Wild Apricot Membership Software