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  • Writer's pictureMonica Jones

Documentation and billing examples

Updated: Jun 19, 2023

Include occupational therapy wording in your documentation to distinguish your role. The OTPF is an excellent resource for this. Depending on your EMR your SOAP note will vary. An adult SOAP note in Cerner might look like this:


Subjective: Pt was willing to participate in therapy today.


Objective: Self-regulation, infant massage, active recreation, home management, performance patterns and routines, attention and memory, socialization, action plan


Assessment: Pt tolerated therapy well. Pt was able to complete 5/6 components of action plan independently. Worked with pt to develop plan to participate in exercise 2x/week for at least 30 minutes (running) and complete 1 home mgmt task independently without complaint (organizing dresser). Introduced executive functioning strategy to improve working memory (errorless learning). Completed infant massage with min A to use as an additional coping strategy and to improve performance with caregiving. Introduced coping strategy to use when socializing (rating worry before and after).


Plan: Cognitive distortions worksheet, activity scheduling


Education: Pt demonstrated/verbalized understanding of activities completed today and HEP (action plan).


  • In this example, for a 60 minute session, I would bill 2 units of 97530, 1 unit of 97129, and 1 unit of 97130.


A pediatric soap note may look like this:


Subjective: Pt transitioned into therapy without complaint and was accompanied by MOC to appt.


Objective: Zones of Regulation lesson 12, heavy work, worry jar craft, sleep hygiene, action plan


Assessment: Pt tolerated therapy well. Pt imitated 10 yoga poses with min verbal and visual cueing, in preparation for tabletop tasks. Pt was able to match the size of a problem and reaction to match "zone" with min A. Completed "worry jar" craft to use as coping strategy and demonstrated use with min A. Collaborated on sleep hygiene strategy to use this week (turning off screens 30 min before bedtime 5/7 trials).


Plan: Zones lesson 13, mindfulness exercise, thinking errors worksheet


  • In this example, for a 60 minute session, I would bill 1 unit of 97530, 1 unit of 97110, 1 unit of 97129, and 1 unit of 97130.


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