I am a licensed Occupational Therapist with over five years of experience working in a skilled nursing facility — and for that entire time, I was the only OT in the building.
There was no mentor down the hall.
No one double-checking my notes.
No one telling me if my documentation was “good enough.”
I learned the hard way how to:
Write audit-safe, PDPM-appropriate documentation
Justify skilled OT services clearly and confidently
Document limited progress, refusals, and medical complexity
Sound skilled even on difficult or unproductive days
This toolkit was created for new grad OTs who are walking into SNFs feeling unsure, overwhelmed, or afraid of “doing it wrong.” My goal is to give you clear guidance, real examples, and confidence so you can focus on being a great clinician — not panicking over your notes.
You don’t need to guess.
You don’t need to reinvent the wheel.
You just need a starting point.
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