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Hysio Occupational Therapy
AI Voice-Driven Reporting for occupational therapists
Discover the report layout built around meaningful occupation, activity, person and environment. This page shows how consultation, intake, home visit and evaluation organise documentation for occupational therapy.
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Quick answer Occupational therapy reports for each care encounter 50 questions with cited sources
Quick answer
Occupational therapy reports built around meaningful occupation
Four formats that clearly organise activity, person, environment and goal achievement.
For this profile, Hysio describes four documentation formats: a consultation, an intake, a home visit and an evaluation built around meaningful occupation. The layout keeps person, occupation and environment clearly side by side, so that a task or home observation does not disappear into general care language.
- How does it work around meaningful occupation?
- What you say about occupation, task and environment becomes an occupational therapy report. That is voice-driven reporting, also called AI documentation. Hysio has four formats: consultation, intake, home visit and evaluation. [6] [7]
- What stays tied to the source?
- An observation of the home, a COPM score or an agreement only goes into the report if you mentioned it in the contact. [1] [6]
- Who determines the content?
- You assess task, environment and assistive devices and choose which text goes into the record. The report follows what you saw and said. [1] [8]
- Status 4 profession-specific documentation formats: Hysio Occupational Therapy Consultation, Hysio Occupational Therapy Intake, Hysio Occupational Therapy Home Visit, Hysio Occupational Therapy Evaluation.
- Source role What the client wants, what you see and what you conclude stay separate.
- Boundaries Hysio does not choose an assistive device and does not add a home measurement or COPM score.
- Responsibility The occupational therapist reads the report through and decides what goes into the record.
Voice-driven reporting around meaningful occupation
Which documentation format belongs to a consultation, intake, home visit or evaluation? #
Occupational therapy has four formats: consultation, intake, home visit and evaluation. The choice fits the activity and context of the encounter. As a result, the course of treatment, meaningful occupation, home observations and goal achievement stay clearly separate from each other. You safeguard activity, environment, professional assessment and the final record text. The consultation follows an ongoing treatment encounter, the intake the first conversation, the home visit an observation in the home and the evaluation an interim or final moment. With voice-driven reporting, a home visit thus stays separate from the treatment encounter. [2] [3] [4] [5] [7] [8]
What does the occupational therapy consultation record about occupation? #
This format turns a treatment encounter into a clear occupational therapy daily journal entry. It keeps the course of meaningful occupation, the procedures carried out, the assessment, the consultation with others and the arrangement for the next encounter clearly apart. Only what you stated during the encounter or provided as a source is included. An intervention, measurement or arrangement that was not mentioned stays visibly absent instead of being filled in. [2] [8] [6]
How does the intake organise living, work and leisure? #
This format organises the first conversation, from referral and the client's request for help to functioning in living/self-care, work/school and leisure/play. Examination, occupational therapy analysis, meaningful goals, agreements and separate consents stay precisely linked to what the client, the client system and the occupational therapist actually contributed. An occupational therapy intake therefore records what was discussed, not what is probably going on. Consent for treatment, for data sharing and for consultation with third parties are recorded as three separate decisions. [3] [6] [7]
What does Hysio record during an occupational therapy home visit? #
The home visit layout only processes home and task observations that the practitioner describes aloud or provides as a source. Task performance, concrete features of the environment, the client's perspective, professional assessment, assistive devices discussed and follow-up each get a recognisable place. Hysio does not pretend to have looked around the home independently and does not add a safety or accessibility judgement that was not stated. [4] [7] [8]
Which goals and measurement results go into the occupational therapy evaluation? #
This format turns an interim or final evaluation into a report of meaningful goals, measurement results, the client's perspective, the occupational therapy judgement and aftercare. An occupational therapy evaluation only records what was actually discussed during that encounter. Check whether every conclusion goes back to recorded information, so that the record remains traceable within this occupation-focused profession. If a main goal or treatment plan was adjusted in the interim, the client's renewed agreement should be stated explicitly or marked as missing. [5] [8] [6]
What do you note after an ongoing occupational therapy treatment contact? #
The consultation report is intended for an ongoing treatment encounter within occupational therapy. Record what the client reports, which activity or environment was discussed, what you observed and which intervention or arrangement follows. A broad initial inventory belongs in the intake and a home observation in the home visit report. You check the source before text goes into the record. [2] [6] [7]
Which intake information does Hysio organise around meaningful occupation? #
This answer explains the structure for the intake within occupational therapy. The intake organises the request for help and functioning in living and self-care, work or school, and leisure or play. What the client or the client system says, examination findings, professional analysis and meaningful goals stay recognisable. What the client names as the most important activities stays in the client's own words. Environmental factors that were not discussed are not filled in. The occupational therapist assesses whether the chosen activities and context really belong to this first conversation. [3] [7] [8]
When do you choose a home visit report in Hysio? #
The choice described belongs to the format for the home visit within occupational therapy. The home visit report is intended for an encounter in which task performance and the actual living environment are central. Only describe what was observed on site or reported by a source who was present. The layout separates features of the home, the client's perspective, assistive devices, professional interpretation and the agreed follow-up. For a regular treatment encounter without a home observation, the consultation report is a better fit. [4] [8] [6]
How does each occupational therapy format fit the type of care encounter? #
This overview concerns formats for occupational therapy. For occupational therapy, a consultation, intake, home visit and evaluation are described. These formats match the type of care encounter and whether meaningful occupation, context, home observation or goal achievement is central. So you choose by purpose of contact, not by topic: the same theme can come back in an intake, a home visit and an evaluation with a different source role and a different follow-up. [2] [3] [4] [5] [8] [6]
Why are activity and context central to an occupational therapy report? #
Occupational therapy looks at meaningful occupation and at the interaction between person, activity and environment. A report therefore becomes more concrete when it describes which task is important, in which context it takes place and what supports or hinders occupational performance. The professional guideline organises that functioning into living and self-care, work or school, and leisure or play. Hysio brings that information together clearly; the choice of a suitable intervention stays with you as the occupational therapist. [3] [4] [6] [7]
Meaningful occupation in context
Since when has occupational therapy been directly accessible without a referral? #
Occupational therapy has been directly accessible since 2012; a referral is therefore not always needed. Under direct access, the occupational therapist carries out the screening themselves and bears responsibility for the outcome and any referral back. Record the route of access, findings, conclusion and communication with the GP or other referrer separately, so that the follow-up stays traceable. [1] [6] [7]
Is documentation within an occupational therapy session billable separately? #
According to the cited NZa policy rule, documentation, communication and correspondence are part of the session; indirect time is not billable as a separate service. Always check the current policy rule and contract agreements before you invoice, because services can change. In the record, do keep the client's perspective, factual observations, professional interpretation and follow-up arrangements recognisable as separate information. [1] [7] [8]
When does an occupational therapist consult the GP under direct access? #
As an occupational therapist, contact the GP when the screening under direct access raises doubts, or when feedback is required under the professional guideline. Record what prompted the contact, which information was shared, who the answer came from and which follow-up was agreed. An attempt at telephone consultation is not yet substantive advice and should therefore stay recognisable as such. [1] [8] [6]
How do you keep occupational therapy documentation workable without losing record quality? #
Workable documentation starts with the information needed for this care encounter: the client's perspective, relevant observations, your professional assessment, interventions carried out and the agreed follow-up. Keep those parts clearly separate from each other and do not include background data that plays no role in current care. That way, the record stays compact and a next reader can follow the reasoning and decisions. [1] [6] [7]
What does the evaluation record about meaningful goals? #
This structure is for the evaluation within occupational therapy. The evaluation records which meaningful goals were assessed, which measurement results or observations are available, how the client experiences progress and which professional conclusion was stated. A COPM outcome is copied literally, without selecting from it or recalculating it. Make clear whether the process continues, is adjusted or ends. Aftercare and goal achievement that were not discussed are not inferred from earlier information. [5] [7] [8]
How does Hysio organise an occupational therapy follow-up consultation? #
A follow-up consultation is organised as a compact daily journal entry: first the course of meaningful occupation, then interventions carried out, the client's response, your assessment, consultation with others and the next appointment. That way, every occupational therapy consultation keeps the same fixed order. The main goal from the treatment plan sits above it as a fixed anchor, so the course can be read against that goal straight away. A new intake question or home observation does not automatically end up in this report. [2] [8] [6]
How do person, activity and environment stay recognisable in the intake? #
For the intake within occupational therapy, this concerns a fixed three-part division in the report. First describe what the client themselves wants or experiences. Then record which activity is central and which physical, social or organisational environment influences occupational performance. Examination findings and your professional analysis also get their own place. That way, it stays visible whether a bottleneck mainly belongs to the person, the task or the context, without filling in a missing factor yourself. [3] [6] [7]
Which home observations belong in a home visit report? #
Think of the accessibility of the home, the facilities present, the rooms in which the task takes place, assistive devices used and the measurements or heights you named aloud. In the home visit format, the task described, factual features of the home, the client's perspective, your assessment, assistive devices discussed and the follow-up each get their own place. Only what you observed on site or what a source who was present reported belongs there. The layout does not add an independent safety or accessibility judgement about the home. [4] [7] [8]
Which source roles does Hysio keep apart in a home visit report? #
This is the structure of the home visit. What the client says, what a partner, informal carer or other close relative contributes as the client system, what you observed on site and what you conclude as the occupational therapist remain four separate roles. The purpose of the visit, assistive devices, strategies and the agreed follow-up are also kept separate. That way, a reader can never read a statement by a relative as a statement by the client. Hysio does not pretend to have looked at a home independently. [4] [7] [8]
When do I choose the occupational therapy evaluation? #
The evaluation is intended for the moment when you discuss goals, results, the client's perspective, assessment and next steps of an occupational therapy programme. The format is intended for interim or final use. Hysio does not record goal achievement based on assumptions and does not put a new goal in the report if it was not discussed during the evaluation. [5] [8] [6]
Guideline and occupational therapy record
Which WGBO obligations apply to occupational therapy record keeping? #
The WGBO regulates, among other things, the duty to inform, consent, the duty to keep records, the duty to retain records, confidentiality and disclosure of data within the treatment relationship. For occupational therapy record keeping, this means that only necessary care information is recorded and that it stays clear who the source is. For legal time limits, always use the current text of the law, because an older professional guideline may contain outdated figures. [1] [8] [6]
Which retention period does the occupational therapy guideline state for records? #
The current general retention period for a medical record is at least twenty years, counted from the moment the data was recorded, or longer when good care practice reasonably requires it. The older occupational therapy guideline still states fifteen years and is outdated on this point. Therefore base the practice retention period on the current WGBO and only record a different, longer retention period when there is a valid reason for it. [1] [7] [9]
When can a client request destruction of an occupational therapy record? #
A client can request destruction of the whole record or part of it. According to current government information, such a request is generally carried out within one month. Refusal is only possible in exceptional situations, for example when another person has a compelling interest or when there is a legal ground for retention. Record the request, the assessment, the decision and the date of execution in a traceable way. [1] [7] [10]
What does an occupational therapist record when data is disclosed to third parties? #
Professional confidentiality is set out in article 7:457 of the Dutch Civil Code (BW). The guideline cites the same article functionally: without the client's consent, the occupational therapist may in principle not provide information, access or copies to anyone other than the client; when information has been provided, case law requires recording to whom, when and which information was given. Colleagues and substitutes directly involved in the treatment do not fall under this, insofar as they need that data for their own work. [1] [8] [6]
How do consent and the duty to inform apply within occupational therapy? #
Treatment requires the client's consent; for procedures that are not invasive, consent can sometimes be assumed. The duty to inform requires an explanation of the nature, purpose, consequences, risks and reasonable alternatives. For children up to the age of twelve, the parents or guardian decide; from twelve to sixteen, consent from both the child and the parents is needed; and from sixteen, the client decides. Record which information was given and which choice was made. Keep consent for treatment, data sharing and consultation with third parties separate. For voice-driven admin too, you ask beforehand whether you may record the conversation. [1] [6] [7]
Is occupational therapist a protected title under the Wet BIG? #
Occupational therapist (ergotherapeut) is a protected educational title under article 34 of the Wet BIG. It does not come with mandatory registration in the BIG register, as it does for article 3 professions. The field of expertise and the training requirements are set out in further regulations. Describe this professional status precisely and do not suggest that an occupational therapist has a BIG number because of the title. [1] [7] [8]
Which quality laws does the guideline mention for occupational therapy practices? #
The older guideline still refers to the former Kwaliteitswet zorginstellingen (Care Institutions Quality Act) for quality policy, and to the Wet bescherming persoonsgegevens (Personal Data Protection Act) for privacy. The current general quality framework for care providers is the Wkkgz; for data protection, the GDPR and the UAVG (Dutch GDPR Implementation Act) apply. Therefore always assess the applicable law and the position of your own type of practice. Only record complaints, incidents and quality measures in the place and according to the procedure designated for this within the organisation. [1] [8] [6]
What is the purpose of the Richtlijn Verslaglegging Ergotherapie? #
The guideline is a fully revised version of the Minimumeisen Verslaglegging Ergotherapie (minimum requirements for occupational therapy documentation) from 2000 and was published in 2016 by Ergotherapie Nederland. It was written to promote uniformity in the occupational therapist's way of working, with the aim of improving the quality of treatment. The key words are effective, efficient and client-centred. That is why the guideline determines which parts a report should contain, not which text you ultimately save in the record. [1] [6] [7]
Which sources belong to an occupational therapy assessment? #
For occupational therapy, this describes how the documentation format works. An occupational therapy assessment can draw on the client's perspective, observations of activity and context, relevant record information, measurement instruments and professional expertise. The source role should stay recognisable. A report must not suggest that a relative, referrer or workplace said something when only the occupational therapist described it. [3] [4] [5] [6] [7]
How does Hysio make the difference between person, activity and environment visible? #
For occupational therapy, this describes what the documentation format keeps apart. The documentation formats offer separate places for what someone can do or experiences, what the task requires and which environmental factors influence occupational performance. As a result, it stays visible where a bottleneck comes from and which information is still missing. Hysio does not add a detail about the home or a personal factor. That keeps voice-driven reporting honest about what you actually saw. [3] [4] [7] [8]
Activity, person and environment
How do you use the COPM in an occupational therapy report? #
The COPM uses a semi-structured interview to map which activities the client considers important and how performance and satisfaction are rated. The client chooses a maximum of five priorities and gives two scores from 1 to 10 for each priority. Record the measurement moment, the chosen activities and the scores given by the client literally. A change only becomes meaningful when the measurement moments are comparable and the occupational therapist interprets the outcome in the context of everyday occupation. [1] [7] [8]
When do you use a measurement instrument from an adjacent field in occupational therapy? #
Some instruments used in practice come from an adjacent field, such as the Barthel Index, MMSE or Jamar hand dynamometer. Therefore name the instrument, purpose, administration context, source and outcome instead of automatically labelling the instrument as occupational therapy. The occupational therapist decides whether the measurement is appropriate and what professional meaning it is given. [1] [8] [6]
How does occupational therapy use the ICF in documentation? #
The guideline uses the ICF to organise problems in functioning, examination data, the occupational therapy diagnosis and goals or results, and strongly recommends that framework. It is about organising in words; coding with b, s, d or e codes is not mandatory. The framework helps to describe person, activity, participation and environment in relation to each other. Only use domains supported by the source and keep a factual observation separate from the professional analysis. [1] [6] [7]
What is service code list 077 used for in occupational therapy? #
For occupational therapy, service code list 077 (prestatiecodelijst) is used within the Generieke Declaratiestandaard Paramedie (generic claims standard for allied health), introduced on 1 January 2025. The code describes the service claimed and does not replace substantive documentation of the encounter. Before claiming, check the current NZa rule, contract agreements and code list. In the record, also keep goal, care provided, assessment and follow-up separately traceable. [1] [7] [8]
How does occupational therapy use diagnosis code list 013? #
Diagnosis code list 013 supports the diagnosis entry for occupational therapy. Since 1 January 2025, only one diagnosis is stated on the claim and the earlier distinction between referral diagnosis, medical diagnosis and allied health diagnosis no longer applies. Check the current code list before you submit a claim and do not confuse a claims code with the full professional analysis in the record. [1] [8] [6]
When do you record an AGB code and UZI number in occupational therapy? #
The AGB code identifies the care provider in administrative and claims processes; the UZI number supports identification within secure healthcare communication. Only record the identification field that the route in question requires and do not copy a number from an old source without checking it. This administrative identification does not replace the substantive source role, assessment and approval of the care encounter. [1] [6] [7]
What is the purpose of the occupational therapy evaluation report? #
The evaluation report makes the course of goals and everyday occupation traceable at an interim or final moment. Describe the result, process, the client's perspective, your assessment and the agreed follow-up separately. A measurement only becomes meaningful when instrument, moment and outcome are recorded; discharge is only mentioned when it was actually discussed. [5] [7] [8]
How does a treatment encounter become a usable daily journal entry? #
This is the structure of the consultation within occupational therapy. A treatment encounter becomes usable as a daily journal entry when the text sets out the current goal, the activity or intervention carried out, the client's perspective, your interpretation and the follow-up in chronological order. Keep a look back separate from a new arrangement. That way, a next reader can see what was actually done and decided during this session. [2] [8] [6]
Can Hysio independently assess a home situation? #
Hysio does not assess a home situation independently. The home visit format only organises home and task observations that you record as a source. Note which situation you saw, which activity was discussed and which request for help or arrangement followed from it. The professional assessment and the follow-up stay with the occupational therapist who carried out the encounter. [4] [8] [6]
How do I include a measurement instrument in an occupational therapy report? #
For occupational therapy, this concerns the report structure. Only name the instrument, the purpose, the measurement moment and the outcome when that data was recorded in the encounter. Link a score to the activity or participation it relates to. Hysio does not fill in a cut-off value, norm score or improvement when it is not supported by the source or your wording. [3] [5] [6] [7]
Occupational therapy in practice: costs, privacy and getting started
What does voice-driven reporting cost for an occupational therapist with their own practice? #
An individual Starter plan from Hysio costs from €20 per month, excl. VAT; Pro costs €40 and Unlimited €80 per month. With yearly billing, you pay for ten months and get twelve. Always check the pricing page for the current plans and terms. Then compare the plan with your encounter volume, the size of your team and the way you check occupational therapy reports and transfer them into your record process. [1] [11]
What should and shouldn't you record about the home, work or school? #
Limit the input to information needed for the care purpose, especially regarding the home, work, school or the client system. Make local agreements about recording, access, review and transfer to the record. The practice remains the data controller, while Hysio acts as the processor. Check the current privacy policy and legal information for processing, hosting and terms. [1] [13]
Is a Hysio report automatically saved in my medical record system? #
Automatic saving in your practice's medical record system or medical record is not available. Hysio is not directly connected to an electronic client or medical record system. You review the report text and transfer suitable parts yourself according to the local route. For a home visit, these are task performance, home findings, the client's perspective, advice and follow-up. Check with your supplier which transfer is possible; this page does not claim any specific integration. [1] [15] [14]
How do you assess the reliability of a Hysio occupational therapy report? #
This review approach describes the occupational therapy route. Put the report text next to the original source and assess person, activity, environment and timeline separately. For a home visit, pay attention to the difference between a factual home observation, the client's perspective and your professional assessment. Hysio output remains working material and can contain errors. Correct source roles, omissions and overly firm conclusions before you approve. Only you decide which text can responsibly go into the record. [1] [14]
Does voice-driven reporting make sense alongside your own template or dictation function? #
Possible alternatives are writing by hand, your own fixed template, a general dictation function or a specialised platform. A short, exceptional encounter can be recorded more quickly by hand. Beyond that, the Hysio route is designed to organise meaningful occupation, context, observations and follow-up recognisably. Compare solutions on source roles, professional terminology, correction time, privacy and the way parts move into your own record process. [1] [14]
Can you test Hysio free for 14 days with home visits and consultations? #
Yes, you can try Hysio free for 14 days; no credit card is needed. Assess how many corrections are needed and how usable the text is for your record route, while environment, the client's perspective, home observations and goals stay properly separate. Compare different encounter types on the same points and check every source before you transfer text. Note which parts of the record you add yourself. [1] [12] [11]
How do you measure whether the report of a home visit is finished faster? #
Measure profession-specific time savings in practice with a fixed comparison. Track recording, generating, reviewing, correcting and transferring separately. Compare consultations, intakes and home visits separately, because home and context information may require more review. Besides minutes, also note missed sources, corrected wording and record quality. The relevant outcome is the net change in your own practice, not a general percentage. [1] [14]
Which occupational therapy contact do you start with when introducing it? #
First prepare the review arrangements: record how the client's perspective, activity, environment, consent and follow-up are checked. Then start with the encounter type you conduct most often and agree who reads the text before it goes into the record. Only add a home visit once home observations and professional assessment stay reliably separate. [3] [13] [14]
Does Hysio give occupational therapy advice itself? #
This sets the limits of how the documentation formats for occupational therapy work. Occupational therapy advice remains your professional decision. Only record a choice of assistive device or adaptation if you have established it as a proposal or arrangement. The platform does not independently decide what someone should do at home, at work or at school. Therefore clearly distinguish the client's perspective, your assessment and an agreed follow-up from each other. [4] [5] [7] [8]
How do I use the occupational therapy report in my record? #
Read through the report for task, context, source role, observation, professional assessment and follow-up. Above all, check that a factual home observation has not turned into a general conclusion and that the client's perspective stays recognisable. Then you decide which version you save in your record and which additional information is still needed. [2] [3] [4] [5] [8] [6]
Sources
- 1 Hysio: Beroepsprofiel ergotherapie (interne Hysio-documentatie) Document date: 2026-08-24 Accessed on 2026-08-31
- 2 Hysio: Hysio Ergotherapeutisch Consult (interne Hysio-documentatie) Document date: 2026-08-24 Accessed on 2026-08-31
- 3 Hysio: Hysio Ergotherapeutische Intake (interne Hysio-documentatie) Document date: 2026-08-24 Accessed on 2026-08-31
- 4 Hysio: Hysio Ergotherapeutisch Huisbezoek (interne Hysio-documentatie) Document date: 2026-08-24 Accessed on 2026-08-31
- 5 Hysio: Hysio Ergotherapeutische Evaluatie (interne Hysio-documentatie) Document date: 2026-08-24 Accessed on 2026-08-31
- 6 Ergotherapie Nederland: Algemeen beroepsprofiel ergotherapeut Document date: z.d. Accessed on 2026-08-31
- 7 Ergotherapie Nederland: Richtlijn Verslaglegging Ergotherapie Document date: z.d. Accessed on 2026-08-31
- 8 Ergotherapie Nederland: Beroepscode ergotherapeuten Document date: 2020 Accessed on 2026-08-31
- 9 Rijksoverheid: Hoelang wordt mijn medisch dossier bewaard? Document date: z.d. Accessed on 2026-08-31
- 10 Rijksoverheid: Mag ik gegevens in mijn medisch dossier laten vernietigen? Document date: z.d. Accessed on 2026-08-31
- 11 Hysio: Actuele Hysio-prijzen (interne Hysio-documentatie) Document date: 2026-08-26 Accessed on 2026-08-31
- 12 Hysio: Actuele proefperiode (interne Hysio-documentatie) Document date: 2026-08-31 Accessed on 2026-08-31
- 13 Hysio: Hysio Privacyverklaring (interne Hysio-documentatie) Document date: 2026-07-16 Accessed on 2026-08-31
- 14 Hysio: Hysio Disclaimer (interne Hysio-documentatie) Document date: 2026-07-16 Accessed on 2026-08-31
- 15 Hysio: Hysio en medische dossiersystemen (interne Hysio-documentatie) Document date: 2026-07-16 Accessed on 2026-08-31
Hysio creates the report. You remain responsible for what you save in the record.