In the realm of occupational therapy, accurate and comprehensive clinical documentation is crucial for assessing and supporting a client's functional capacity. This blog post will guide you through the process of writing and formatting a Functional Capacity Assessment using a detailed template. We will also explore how AI medical scribes, such as Notis AI Medical Scribe, can streamline and enhance this documentation process.

The Functional Capacity Assessment is a vital tool used to evaluate a client's ability to perform daily living activities. The following sections outline how to effectively document this assessment with clarity and precision.

Begin by recording the client's basic information. This includes the client's name, date of birth, and any relevant identification numbers. For example:

Client Information:
- John Doe
- 12/05/1985
- NDIS123456789

It is important to note the date of the assessment to provide context for the findings. Example:

Assessment Date:
- 15/09/2025

Include the assessor's name, professional title, and contact information to ensure accountability and communication. Example:

Assessor Information:
- Dr. Jess Spencer
- Occupational Therapist
- jess.spencer@healthcare.org

Clearly state why the client has been referred for assessment. This section sets the stage for understanding the purpose of the evaluation. Example:

Reason for Referral:
- To assess the client's functional capacity for daily living activities and recommend appropriate support services.

Provide a brief history of the client's condition and living situation to give context to the assessment. Example:

Background Information:
- John has a history of traumatic brain injury sustained in a car accident five years ago.
- He lives alone in a one-bedroom apartment and receives weekly visits from a caregiver.

This is the core of the document. Detail the client's physical, cognitive, communication, social, and emotional capacities. Example:

Functional Capacity Assessment:
- John demonstrates limited physical capacity, with reduced strength and coordination in his right arm.
- Cognitive capacity is affected, with difficulties in memory retention and problem-solving.
- Communication capacity is adequate, though John occasionally struggles with word retrieval.
- Social and emotional capacity is stable, but John reports feelings of isolation.
- Daily living skills are compromised, requiring assistance with meal preparation and personal hygiene.

Summarize the findings and propose interventions or support services. Example:

Summary and Recommendations:
- John exhibits significant challenges in physical and cognitive domains, impacting his daily living skills.
- It is recommended that John receives occupational therapy twice a week, along with continued caregiver support for daily activities.

Conclude with the assessor's signature and the date to validate the document. Example:

Assessor's Signature:
- Jess Spencer
- 15/09/2024

While manual documentation is essential, it is often time-consuming. This is where AI medical scribes like Notis AI Medical Scribe can revolutionize the process for occupational therapists. Notis leverages advanced voice-to-text technology to transcribe patient interactions and generate structured SOAP notes, significantly reducing the time spent on documentation.

Key Benefits of Using Notis AI Medical Scribe:

1. Time Efficiency: Notis reduces documentation time by up to 80%, saving healthcare providers approximately 2 hours per day. This efficiency allows therapists to focus more on patient care and less on administrative tasks.

2. Ease of Use: With its integration into WhatsApp, Notis offers a familiar interface, eliminating the need for additional software and making it user-friendly.

3. High Accuracy: Notis provides 99% accuracy in transcribing medical notes, ensuring that clinical documentation is reliable and precise.

4. Comprehensive Documentation: Notis automatically organizes notes into the SOAP format, facilitating thorough and structured patient documentation.

By incorporating AI medical scribes into the workflow, occupational therapists can enhance the accuracy and efficiency of their documentation, ultimately improving patient care. Notis AI Medical Scribe represents a significant advancement in the field, offering a seamless solution for occupational therapy documentation needs.