Trusted from independent practitioners to community services
The falls and home assessment, any capacity considerations and the goals, Note Dr writes the full, watertight older-adult record, ready to approve.
Get Note Dr free→Trusted from independent practitioners to community services
Note Dr listens to the visit as it happens. While you take the occupational history, watch a transfer and reason aloud about the home, it writes the record in the background, so your eyes stay on your client and off the keyboard.
Capacity and consent on record
The capacity consideration you made and the consent your client gave to equipment and adaptations, recorded the moment you reach it, not reconstructed later.
Client-centred goals and outcomes
The occupational goals you agreed in your client's own words and the outcomes against them, the very elements audits show go missing most.
Equipment and adaptation rationale
Every piece of equipment recommended, the safety reasoning behind it and the home hazards it addresses, captured as you talk it through.
A reviewed Note Dr record captures more of what a record needs to stand up to scrutiny, the occupational profile, client-centred goals, intervention reasoning and outcomes, where published standards and audits show conventional OT records routinely fall short.
Standards and audits referenced: the HCPC standards of proficiency and the RCOT professional standards and Keeping records guidance, with a documentation audit of 320 records (Gibson et al, British Journal of Occupational Therapy, 2004).
Ask what you assessed last time, the goals you agreed, or what your client consented to, answered in seconds from their own record.
Walk into the home visit already knowing the story, without trawling the notes.
When a presentation calls for it, Note Dr surfaces the published guidance occupational therapists work to, from the HCPC Standards of Proficiency and the RCOT professional and record-keeping standards to NICE falls guidance and outcome measures such as the COPM, with the source shown. It never tells you how to treat your client; that judgement stays with you.
Want me to surface any guidance for this? You could ask:
Why occupational therapists trust Note Dr with a record that stands up to scrutiny.
★★★★★
The occupational story is finally there
Half of what a client tells me about how they live used to never make the note. Now the occupational profile and their own goals are right there in their words. I read it through, edit and approve in under a minute.
★★★★★
Capacity and consent, never missed
Recording the capacity consideration and consent for equipment used to be the bit I wrote up hours later. Now what I weighed up and what the client agreed to is in every assessment, which is exactly where my exposure sat.
★★★★★
Equipment reasoning, captured
Every rail and bath board I recommend now has the hazard and the reasoning beside it, captured as I talk it through in the home. If anyone ever questions a recommendation, the why is already on the record.
★★★★★
Home visits, written before I leave
I'm not driving back with a head full of notes to write up any more. The functional assessment and the home hazards are documented by the time I'm out the door. My evenings are my own again.
★★★★★
Calmest audit the team has had
Contemporaneous records across the team, with goals, capacity and outcomes on every episode. Our last RCOT-standards audit was the smoothest we have run. The notes already evidenced the whole occupational picture.
Every recording and record is protected by strong, independently assessed security and encryption.
★★★★★
Across a full older-adult caseload, home assessments, reviews and discharges, every record now reads to the same standard, with the occupational goals, capacity considerations and outcomes that used to vanish when I was rushing between visits. My notes finally match the work I actually do.
Imogen FGeriatric occupational therapist
Yes, provided you remain accountable for every word that enters the record. UK professional standards for occupational therapists expect you to understand any AI tool you use, review its output and stay responsible for the result. Note Dr is built around that duty: it drafts the note from the consultation, and nothing is saved until you have read, edited and approved it. The record stays yours.
Yes, Note Dr is designed for the home visit: it listens on your own device in the client's home and drafts the record while you assess. The occupational profile, transfers, falls history and room-by-room hazards are captured as you reason aloud, with a relative's or carer's contribution part of the story. You review and approve the note before it reaches the record, usually before you leave.
The same way as consent for any other part of the visit: you explain in plain language that a scribe will help you write the note, check understanding, and involve family or an advocate where appropriate, in line with mental capacity legislation. Note Dr records that consent discussion. If consent is not given, or you judge it inappropriate that day, you document it another way.
Yes, when you administer an outcome measure aloud, the Canadian Occupational Performance Measure, the Barthel Index or your service's own tool, the scores you state and your interpretation are drafted into the note. At review, the measure sits beside the goals, so progress is evidenced, not asserted. You check every figure against your scoring sheet before approving the record.
Yes. As you assess transfers, mobility and activities of daily living and talk through the falls history and contributory factors, Note Dr records the functional baseline and the falls picture in a structured note. These are core to the older-adult record, and you review and approve before saving.
Yes. As you assess the environment room by room and recommend equipment and adaptations, Note Dr records the hazards you identify, the equipment you propose and the safety reasoning behind each. The home and equipment assessment is documented as you talk it through, ready for you to check.
Yes. Note Dr records the occupational goals you agree in your client's own words, the outcomes against them at review, and the discharge summary with equipment in place and self-management advice. What a client tells you independence means to them, and their felt progress towards it, are the first to fade once the home visit is written up later; Note Dr holds them as they are spoken.