What happened around the group
- Service date, start time, and session length
- Individual, group, consult, or makeup service kind
- The task, environment, and skilled OT service provided
- Service context or next step that applies to the whole session
Session documentation
Document individual and group services without repeating the work.
Enter the shared group details once. Keep attendance, minutes, student responses, and goal observations separate for each student.
Session note · ST-014
Practiced opening lunch containers and organizing materials. Four of five steps were completed with one visual cue.
- Attendance
- Attended
- Minutes
- 30
- Status
- Finalized
Group services
Write the shared session once and each student’s response individually.
A shared group note can describe the task, setting, and skilled support. It cannot tell you whether every scheduled student attended, which service requirement each student received, how each student responded, or how many minutes should count.
Copying the same group description into a separate note for every student takes time and creates small differences between records. The School OT keeps the group details together and gives each student their own attendance, minutes, response, and goal observation.
Group and student details
What belongs to the group record and each student record.
Your district determines the official documentation standard. This structure keeps the operational facts connected so the clinician can apply that standard without reconstructing the session.
What happened for this student
- The active requirement served on that date
- Attendance, including the reason service was not received
- Minutes eligible for credit under the configured rule
- Observable response, assistance, cueing, or performance
- Any goal observation captured during the session
Field definitions
How service record fields differ.
Session length and credited minutes
A group may last 30 minutes while one student receives only 20. The session length describes the shared event. Credited minutes belong to the participant and cannot exceed the session length.
Attendance and service kind
“Makeup delivered” says the student received recovery service. “Student absent” says a planned service did not occur for that student. The session can still exist for the other participants.
Shared note and individual response
“Practiced classroom tool use” sets the context. “Opened four of five containers after one visual cue” shows what the service looked like for a particular student.
Draft and completed records
A saved draft has not entered the ledger. COTA work may be complete from the author's perspective and still wait for OTR review. Finalized status is the point at which eligible minutes become part of delivered service.
Group example
One planned group can end with different outcomes.
A 30-minute lunch participation group includes ST-014 and ST-019. The accepted schedule supplies the date, time, provider, participants, and linked requirements. Both students remain on the session record even though only one receives service.
Attended · 30 credited minutes
Opened four of five containers with one visual cue, then organized utensils independently. A percent observation is attached to the active participation goal.
Student absent · 0 credited minutes
No individual response is invented. The attendance result preserves why the scheduled service did not occur and can create recovery work after finalization.
Do not remove the absent student from the scheduled group to make the record look complete. Recording the outcome is what closes the block honestly.
Documentation steps
Start with the scheduled service when it exists.
The event link carries the participants and requirements into documentation and prevents a second session from being tied to the same planned block.
- 1
Open the scheduled service
Confirm the service date, length, provider, and full participant list. If the session was unscheduled, create the record directly and choose the active requirement for each student.
- 2
Record each student’s attendance
Use attended, student absent, provider absent, school closed, excused, or makeup delivered. The configured requirement rule determines whether an excused result is eligible for credit.
- 3
Add each student’s response
For each student who received service, record an individual response. Add goal evidence only when an observation was actually made.
- 4
Save a draft or submit for review
Save a draft when the record is incomplete. Submit when the author has finished it. The workspace role and COTA review policy determine whether submission finalizes or enters review.
Service record status
Use the status to see what happens next.
Draft
The author can finish the shared note. No minutes are final.
Pending review
An authorized OTR can inspect the service and approve it or request a change.
Changes requested
The author revises and resubmits. The earlier review decision remains in history.
Finalized
Eligible participant minutes count in the ledger and finalized goal evidence becomes visible downstream.
Void
The record stops counting. The reason and correction event remain traceable.
Corrections
Correct a service record based on its current status.
Changing a record should not erase the fact that a different version was submitted or finalized earlier.
The record is awaiting review
The OTR requests a specific change. The author revises the note and resubmits it. The reviewer, decision, timestamp, and comment stay with the session.
The finalized record is materially wrong
An authorized user voids it with a reason. Its minutes stop counting, and a linked accepted block can return to planned status so the correct result can be documented.
The plan changed after the session
Leave the session attached to the requirement active on its service date. Create a new plan version for later service instead of moving history to the new requirement.
Completed service record
A completed service record updates service minutes and reports.
- The date, provider, length, and service kind match what occurred.
- Every participant is tied to the correct requirement active on that date.
- Every scheduled student has an attendance result, including students who did not receive service.
- Credited minutes reflect the participant outcome and the configured crediting rule.
- Each attending student's response is specific enough to distinguish that student from the group.
- Goal evidence is observable, attached to the correct goal, and uses the measure actually collected.
- The record is submitted, reviewed when required, and finalized before you expect it in the ledger or report evidence.
FAQ
Record each student’s individual outcome.
Can I document a service that was not on the accepted schedule?
Yes. Create an unscheduled record, choose the active requirement for every participant, and enter the service facts directly. It should still follow the same attendance, response, review, and finalization rules.
Why must every scheduled student stay on the group record?
The accepted block represents a planned service for each participant. Removing a student hides the outcome. Keep the student on the record and choose the attendance result that explains what happened.
Does the product write the clinical note?
No. The clinician authors the shared note and each individual response. The School OT keeps those words connected to the schedule, requirement, review, and service ledger.
When do goal observations appear in the student record?
Observations entered outside a session can appear directly. Observations attached to a session are included downstream only when that session is finalized.
Document a service