A guide to your OT workflow.

Set up your workspace

Add a clinic for your document letterhead and a therapist for credentials and signature details. Create a patient record with referral information and caregiver contacts.

The dashboard brings evaluation and therapy documentation tasks together. Patient, clinic, and therapist records remain available across the workflow.

Create an assessment

An assessment represents an evaluation episode for a patient. Assign the clinic and therapist, then select questionnaire categories relevant to the referral.

The catalog includes the Occupational Profile & Priorities, Child's Own View, activities of daily living, play, education, rest and sleep, contexts, performance skills, and other areas. Categories and questions can be customized.

These intake questions organize information; they are not advertised as a standardized diagnostic instrument.

Gather caregiver answers

Download a fillable, letterheaded PDF for the caregiver, or print a paper copy. Import the completed PDF to bring answers back into the matching assessment.

You can also enter answers manually and attach a photograph of the returned paper as a reference. Review the information and its source before preparing the report.

Write an Initial Evaluation

Open a report from the assessment. The SOAP layout separates caregiver-reported information from your observations, assessment, and plan.

• Subjective: occupational profile, referral, chief complaint, and caregiver goals.
• Objective: occupations, performance skills and patterns, client factors, and contexts.
• Assessment: OT impression, strengths, and problems pertinent to OT.
• Plan: your recommendations.

Use optional AI assistance to structure source information and clinical notes. Review each draft, edit it, then finalize. Export a PDF or an editable DOCX.

Plan intervention and record sessions

An intervention plan links to an evaluation. Set occupation-based goals with baseline performance, a target date, and an intervention approach.

In each session note, record activities, the child's response, and the next steps. Add a progress rating for each goal addressed during that session.

Prepare a Progress Report

Create a report from an intervention plan or from your own free-text notes. Set the reporting period and choose your recommendation before requesting an AI draft.

Review the SOAP narrative and goal progress. Finalizing a plan-based report freezes the goal rows and session count for that record. Reverting to draft refreshes them from the plan.

Close or resume an episode

A finalized Progress Report recommending discharge marks the patient as discharged. A draft recommendation does not. Prepare a discharge summary that communicates outcomes and recommendations to the family, school, or referrer.

Readmission can resume the existing plan or begin a new episode. An evaluation for a new episode is titled Re-evaluation.

Issue a Certificate of Completion

Choose a certificate template and review the client's name, completion date, program, clinic details, and therapist details. Clinic branding and signatures come from the linked records.

Once issued, the certificate is locked until you revert it to draft.

Choose optional AI assistance

Settings lets you configure Anthropic, OpenAI, Google Gemini, or a local Ollama endpoint. Cloud providers require your own API credentials. The desktop application also supports configured Claude Code and Codex integrations.

A connected indicator confirms provider availability. AI drafting requires the relevant source information; it cannot supply observations you did not make. Review all generated text.

Cloud AI processes the relevant input with the selected provider. See data handling before using it with clinical records.

Back up your records

The Windows app keeps every record in a database file on your computer. Use Settings to export and restore a backup: one JSON file with every record, including photos, logos, signatures and imported PDFs.

Auto Backup writes that file to a folder you choose every 5, 15, 30 or 60 minutes while OTeva is open. Keep backups somewhere safe, and check now and then that one restores. Backups are not a substitute for your practice's information-handling procedures.