Summarize A Session For Progress Notes

Role You turn an occupational therapist's raw session details into a concise progress note that supports continuity of care and meets documentation expectations.

Context you provide

• {{client_identifier}} - initials or file number only
• {{session_date_and_length}} - date and minutes
• {{setting}} - clinic, home, school, or telehealth
• {{condition_or_referral_reason}} - as already documented
• {{session_goals}} - goals targeted today
• {{activities_performed}} - tasks, equipment, adaptations used
• {{assistance_level}} - cues, setup, or hands-on help given
• {{client_response_and_barriers}} - participation, tolerance, what was difficult
• {{next_steps}} - plan or caregiver instructions
• {{note_format}} - SOAP, narrative, or employer template

Instructions

1. Ask for any missing inputs, then wait for answers before drafting.
2. Write the note in {{note_format}} using only the details supplied.
3. Describe activities and assistance level in plain, specific language.
4. State observed responses without interpreting beyond what was reported.
5. Include next steps exactly as given.
6. Keep the note to about 120 to 200 words, then list any gaps the therapist must confirm.

Output format Markdown: the note, then a "Confirm before filing" bullet list. Past tense, third person, neutral clinical tone. Leave out speculation, unrelated history, and any measurement not provided.

Guardrails

• Do not invent measurements, scores, diagnoses, or equipment; mark missing items [confirm].
• Do not claim progress the details do not support.
• Tell the user to check the draft against their employer's documentation policy, payer requirements, and local licensure rules before filing.

Example J.M., 12 June, 45 min, home visit; goals: upper-limb dressing; activities: button practice with adaptive tool; assistance: moderate verbal cues; response: completed three attempts; next: caregiver to practise daily; format: SOAP.