--- title: "Keep functional baselines and equipment trials where AI can compare progress" description: "Record occupational therapy baselines, equipment trials, home changes, and payer rules in a structured record so AI can compare progress, within HIPAA." canonical: "https://scalewithsearch.com/articles/ai-for-occupational-therapists" date: "2026-01-28" modified: "2026-09-25" --- ## Site navigation - [Scale With Search](https://scalewithsearch.com/) - Real estate - Real estate - [Real estate](https://scalewithsearch.com/for/real-estate) - Work - Start here - [Send your brief](https://scalewithsearch.com/work#send-your-brief) - [Prepare your six-question brief](https://scalewithsearch.com/work#prepare-your-six-question-brief) - Build - [Site build, content library with SEO, signal desk](https://scalewithsearch.com/work) - For your business - Trades and home services - [Auto body and collision shops](https://scalewithsearch.com/for/auto-body-and-collision-shops) - [Foundation and home repair contractors](https://scalewithsearch.com/for/foundation-and-home-repair) - 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A stroke patient needs adaptive equipment for dressing. At evaluation three weeks ago, the affected arm had 2/5 strength, minimal active range of motion, and moderate spasticity. The therapist recommended a button hook, elastic shoelaces, and a dressing stick. Today, strength is 3/5, but buttons are still a struggle. The therapist must decide between a different tool and more practice with the current one. That decision needs today's function compared with the baseline. The EMR holds the evaluation scores. It does not hold the details that change the answer. The patient lives alone. The unaffected hand has arthritis. The patient wears shirts with small buttons for an office job, so elastic-waist clothing is not an option. A general AI assistant does not hold this context either. It can list adaptive equipment. It cannot remember that this patient found the button hook hard to use with an arthritic non-dominant hand. This article shows how to structure the record so an assistant can compare progress, and how to do it inside privacy rules. ## Two records, two sets of rules Occupational therapy context splits into two kinds of record. The practice file holds what you know across patients. It records which equipment works for which impairment patterns, energy conservation methods, and caregiver training approaches. It also records home modification details and payer documentation rules. It holds no patient information. The patient progress record holds one patient's baselines, trials, and changes. It is protected health information. It belongs in the EMR, or in an AI workflow that your organization has approved under a HIPAA business associate agreement with the AI vendor. Without that agreement, patient details do not enter an AI session. Claude Code reads a file named `CLAUDE.md` from the working folder at the start of each session ([Claude Code memory documentation](https://code.claude.com/docs/en/memory), checked 2026.09.25). The files stay on your computer, but the text Claude Code reads goes to Anthropic for processing. Retention and training terms depend on your plan. That fact decides which record may go where. The guide on [what client data belongs in AI agent memory](/articles/client-data-in-ai-agent-memory) gives a field-by-field sorting test. ## Record functional baselines that drive treatment Occupational therapy measures function. Can the patient dress, prepare a meal, manage medications, or return to work? Each activity breaks down into component skills: fine motor control, cognitive sequencing, endurance, and problem solving. Baselines are specific and measurable. At evaluation, the patient buttons three buttons in two minutes with moderate difficulty. The patient prepares a cold meal but not a hot one. The patient remembers morning medications but forgets evening doses. Four weeks later, the patient buttons five buttons in 90 seconds with minimal difficulty. The patient prepares simple hot meals with the microwave. Evening medication adherence improved after you set up a reminder system. A structured progress record connects those data points to the interventions between them. The assistant can then draft a progress narrative that shows which intervention came before which change. You confirm the link. The assistant does not infer causes that the record does not support. ## Track activity tolerance and energy conservation Many patients have limited endurance: patients with heart disease, COPD, chronic fatigue, or post-viral syndrome. They can do activities, but they run out of energy fast. You teach energy conservation. Sit while cooking. Use a shower chair. Pace activities with rest breaks. Change the home to reduce steps and reaching. Progress here is subtle. The patient now cooks dinner without lying down afterward. The patient showers and dresses in the morning and still has energy for the day. Standard outcome measures rarely capture this. Record the patient's own reports and your observations in the progress record, so the change is visible across visits. ## Log equipment trials and outcomes You know what each tool does: reachers, sock aids, weighted utensils, built-up handles, jar openers, one-handed cutting boards, elastic shoelaces, long-handled sponges. Experience teaches you which patients will use which tools. A reacher looks right for a patient who cannot bend down. With poor grip strength, the patient cannot operate it. Weighted utensils help tremor but increase fatigue in patients with weakness. A sock aid works when the patient can learn the technique, but it frustrates a patient with memory deficits. The practice file keeps these lessons as de-identified patterns: ```markdown # Practice file: equipment patterns (no patient identifiers) updated:: 2026.09.25 ## Dressing, one-handed after stroke - Button hook: worked after 2 practice sessions when grip on the unaffected hand was functional. - Button hook with built-up handle: try first when the unaffected hand has arthritis. - Sock aid: failed with moderate memory deficits; compression stockings or clothing changes worked instead. - Some patients reject all dressing aids but accept clothing modifications. ## Feeding, tremor - Weighted utensils: helpful for tremor; watch for fatigue with weakness. ``` When a new patient presents with a similar pattern, ask the assistant which equipment is worth a trial. It answers from your recorded outcomes, not from a generic list. ## Record home safety recommendations in full Home recommendations depend on the specific home. Where are the stairs? Is the bedroom on the first floor? How many steps to enter? Is the bathroom reachable from the bedroom? Are there grab bars, loose rugs, or poor lighting? Placement matters. A patient with balance problems needs grab bars, but their position depends on the toilet and shower layout. A patient with low vision needs better lighting, and the type depends on the existing fixtures. Write each recommendation so the next visit can check it. "Recommended grab bars" is not enough. Record the position: one bar to the left of the toilet, one on the back wall inside the shower. Record the plan: the patient's son installs them within two weeks. Record the check: confirm installation and safe use at the next visit. Record barriers too: cost, landlord limits, or family resistance. ## Track cognitive strategies Many patients have cognitive deficits after stroke or brain injury, or with dementia. These deficits affect how they learn compensatory strategies. You assess attention, memory, problem solving, sequencing, and safety awareness. A patient with memory deficits needs external aids: checklists, labeled cabinets, medication organizers. A patient with sequencing problems needs tasks split into smaller steps. A patient with poor safety awareness needs home changes and caregiver training. Progress is gradual. A patient who could not remember a three-step task now completes four steps with a written list. A patient who left the stove on twice last month has used a timer for three weeks. A patient now uses a pill organizer without help. Record each strategy and how the patient uses it, so the next session builds on it. ## Plan caregiver training Many patients need a caregiver. You train family members or paid caregivers on safe transfers, cueing, task setup, and when to step in or step back. Caregivers learn at different rates. Some master physical techniques fast but struggle to decide when to cue and when to wait. Some follow instructions well but cannot solve an unexpected problem. Some are overprotective and do too much. One reliable caregiver may be available only three days a week, so the patient needs strategies for the other days. Record each caregiver's strengths, gaps, and availability in the progress record. Record the training approaches that worked across caregivers in the practice file. ## Match work and school goals to requirements A return-to-work goal needs the job's demands in the record. An office worker needs computer skills, sustained sitting, and cognitive endurance. A construction worker needs strength, balance, coordination, and work at heights. A teacher needs standing tolerance, fine motor skill for writing, and vocal endurance. Test the specific demands: typing for the required time, lifting the weights the job involves, standing for a full shift. Record employer accommodation options you discussed, such as modified schedules, ergonomic equipment, or job restructuring. When you write the return-to-work letter, the assistant can draft it from those records for your review. Pediatric work follows the same pattern over months and years. A five-year-old who could not hold a pencil now writes their name clearly. A seven-year-old who could not tolerate school assemblies now joins with noise-canceling headphones. A ten-year-old learned a different shoe-tying method. Parents, teachers, and other therapists each see a different part. The record keeps what works at school, what is hard at home, and each adult's strategies in one place. ## Record sensory strategies Some patients over-respond to noise, light, touch, or movement. Some under-respond and seek intense input. Some cannot regulate arousal and swing between overwhelm and shutdown. Strategies are individual: noise-canceling headphones, fidget tools, weighted items, movement breaks, textured materials, dimmed light. Record which strategy helped which symptom. The sensory plan then improves over time instead of restarting. ## Keep payer documentation rules in the practice file Equipment such as wheelchairs, hospital beds, and patient lifts needs authorization. Payers want proof of medical necessity. They want the functional limits, why this item, why a cheaper item is not enough, measurements, and the clinical justification. Coverage for bathroom equipment such as shower chairs varies by payer, and some plans exclude it. Each payer differs. Medicaid rules vary by state. Many private plans require prior authorization. Medicare ended its functional limitation reporting requirement for therapy, the G-codes and severity modifiers, for dates of service from 2019-01-01 (CMS Functional Reporting page, checked 2026.09.25). Record each payer's current requirement with its source and date, so the request goes in complete the first time. ## Set the limits The assistant compares, organizes, and drafts. You evaluate, decide, and sign. It does not choose equipment, set goals, or write a note you have not reviewed. It stops when a comparison needs data that the record does not hold. Some steps should stay manual even with good records. The guide on [when an AI workflow should stay manual](/articles/when-an-ai-workflow-should-stay-manual) helps you decide which ones. To decide what each session should read before it starts, use [what context should an agent read](/articles/what-context-should-an-agent-read). The same structure applies in physical therapy, as the companion guide on [AI for physical therapists](/articles/ai-for-physical-therapists) shows. ---- ```text .|########||. .|########||. .|########||. |##||. .||##|. |##||. .||##|. |##||. .||##|. |#|. .|#|. |#|. .|#|. |#|. .|#|. |#| |#| |#| |#| |#| |#| .#| |#. .#| |#. .#| |#. .#. .#| .#. .#| .#. .#| |#. .#| |#. .#| |#. .#| |# ...... #| |# ...... #| |# ...... #| .# ||#########| #| .# ||#########| #| .# ||#########| #| .#. |######||######|. .#. .#. |######||######|. .#. .#. |######||######|. .#. #. .##|###|##|#|######| .# #. .##|###|##|#|######| .# #. .##|###|##|#|######| .# || |##|#||||||||||||#||#| || || |##|#||||||||||||#||#| || || |##|#||||||||||||#||#| || # |#||||||||||||||||||||#| #. # |#||||||||||||||||||||#| #. # |#||||||||||||||||||||#| #. || |#||||||||||||||||||||||#| || || |#||||||||||||||||||||||#| || || |#||||||||||||||||||||||#| || # .#||||||||||||||||||||||||#| # # .#||||||||||||||||||||||||#| # # .#||||||||||||||||||||||||#| # || ....|||#||||||##|#|||#|#||##||||....|. || || ....|||#||||||##|#|||#|#||##||||....|. || || ....|||#||||||##|#|||#|#||##||||....|. || #. . ....|# ....#||| ||| .#||| ....#. .# #. . ....|# ....#||| ||| .#||| ....#. .# #. . ....|# ....#||| ||| .#||| ....#. .# # . ||||#| .#####|| . .#| .#||| ||||# #. # . ||||#| .#####|| . .#| .#||| ||||# #. # . ||||#| .#####|| . .#| .#||| ||||# #. .| ||||| #. |#|||||. || #. |#||. .||||| || .| ||||| #. |#|||||. || #. |#||. .||||| || .| ||||| #. |#|||||. || #. |#||. .||||| || || |.... #. ....|#. |. ...|. ....|| || || |.... #. ....|#. |. ...|. ....|| || || |.... #. ....|#. |. ...|. ....|| || #. .||||||##||||||##||####|||||||#||||||#| .# #. .||||||##||||||##||####|||||||#||||||#| .# #. .||||||##||||||##||####|||||||#||||||#| .# # .||####|###########################|. # # .||####|###########################|. # # .||####|###########################|. # # .#||||||.#.|| # |. ..# #| #|||||#| # # .#||||||.#.|| # |. ..# #| #|||||#| # # .#||||||.#.|| # |. ..# #| #|||||#| # # .#|||||| .. |# ## |#| ...#|#|||#| # # .#|||||| .. |# ## |#| ...#|#|||#| # # .#|||||| .. |# ## |#| ...#|#|||#| # # .#|||#|# .# .#| #| ##|.#..#|||||#| # # .#|||#|# .# .#| #| ##|.#..#|||||#| # # .#|||#|# .# .#| #| ##|.#..#|||||#| # # .#||||||############|######|||||#| # # .#||||||############|######|||||#| # # .#||||||############|######|||||#| # # |...||#||||||#||||#|#||||||#|||||#||| |.| # # |...||#||||||#||||#|#||||||#|||||#||| |.| # # |...||#||||||#||||#|#||||||#|||||#||| |.| # #. .. ||||# .|||##|. |#| .|| || .|||#. #| # .# #. .. ||||# .|||##|. |#| .|| || .|||#. #| # .# #. .. ||||# .|||##|. |#| .|| || .|||#. #| # .# || | ...|| ...##| | #| .|. |. ##### .. .| || || | ...|| ...##| | #| .|. |. ##### .. .| || || | ...|| ...##| | #| .|. |. ##### .. .| || || ||||| || ||||#| . |. |. |#. ||||| |#| || || || ||||| || ||||#| . |. |. |#. ||||| |#| || || || ||||| || ||||#| . |. |. |#. ||||| |#| || || .# |.....#|....|#.||||.|||##.|#|....||.#||.#. #. .# |.....#|....|#.||||.|||##.|#|....||.#||.#. #. .# |.....#|....|#.||||.|||##.|#|....||.#||.#. #. #.|||||||#############################| ||| .# #.|||||||#############################| ||| .# #.|||||||#############################| ||| .# || ##||#||#||||||#||#||#||#||##. || || ##||#||#||||||#||#||#||#||##. || || ##||#||#||||||#||#||#||#||##. || # .#|||||||||#||#|||||||||||#| # # .#|||||||||#||#|||||||||||#| # # .#|||||||||#||#|||||||||||#| # || |#||||||||||||||||||||||#| || || |#||||||||||||||||||||||#| || || |#||||||||||||||||||||||#| || .# |#||||||||||||||||||||#| #. .# |#||||||||||||||||||||#| #. .# |#||||||||||||||||||||#| #. || |#||||||||||||||||||#| || || |#||||||||||||||||||#| || || |#||||||||||||||||||#| || #. .######|#|#########| .# #. .######|#|#########| .# #. .######|#|#########| .# .#. |#####||||#####| .#. .#. |#####||||#####| .#. .#. |#####||||#####| .#. |# ||########|| #. |# ||########|| #. |# ||########|| #. |# ...... #| |# ...... #| |# ...... #| |#. .#| |#. .#| |#. .#| |#. .#. |#. .#. |#. .#. .#| |#. .#| |#. .#| |#. |#| |#| |#| |#| |#| |#| .|#|. .|#|. .|#|. .|#|. .|#|. .|#|. |##||. .||##| |##||. .||##| |##||. .||##| .||########||. .||########||. .||########||. 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