The Difference Between Evaluation, Progress Notes, and Re-Certification

Initial Evaluation

An Initial Evaluation is the first and most comprehensive assessment completed when a client begins occupational therapy services. It is your opportunity to gather a detailed medical history, understand the client’s occupational profile, perform targeted assessments, analyze functional strengths and barriers, and establish a baseline.
The purpose is simple and powerful:

• Determine functional needs

• Identify occupational performance deficits

• Develop a skilled treatment plan

• Set measurable, occupation-based goals

This establishes the clinical roadmap for all future sessions.

Progress Note

A Progress Note documents the client’s response to intervention over time. These notes reflect:

• Changes in functional performance

• Updated measurements and objective findings

• Client engagement and tolerance

• Treatment provided and clinical reasoning

• Modifications to the plan of care

Progress notes justify medical necessity, track improvement, and ensure continuity of care. They demonstrate why your skilled services matter.

Recertification Note

A Recertification Note is completed when ongoing therapy must be re-authorized or when a plan of care cycle renews. This document includes:

• Updated objective data

• What goals have been met, revised, or discontinued

• Clinical justification for continued therapy

• Functional changes since the last certification

• Any new or evolving needs

Insurers rely on recertifications to determine whether further OT services are warranted based on functional progression and medical necessity.

Featured Resource

Real Examples of Common Rehabilitation Documentation

Check out some examples of documentation used in a clinical setting across a full continuum of care. This is one example and often changes based on the setting you are in.