INITIAL EVALUATION NOTE
Initial Evaluation Note Generator
The first visit carries the most documentation weight: it establishes the baseline everything later is measured against. This structures that visit so the baseline is explicit.
No recording. No account needed to try. Nothing you type leaves your browser.
Works with OT · PT · SLP · BCBA credentials · Insurance, Medicare, Medicaid and school settings · 50-state formats
How compliance works
1Who you are
2This session
3Your note
Fill the form above and press Generate note to see your record here.
How this works
The baseline is the whole point of this note
Every progress note you write for the next twelve weeks will be compared against this document. If the initial evaluation does not state where the client started — with numbers, not adjectives — later progress claims have nothing to stand on. Fill in the accuracy field even if your discipline does not usually use percentages; it becomes your baseline figure.
What payers look for in an initial evaluation
Four things: a referral reason, objective findings from an examination you performed, a clinical impression that connects findings to functional limitation, and a plan of care with frequency and duration. A missing plan of care or a vague frequency statement is the most common cause of a denial at the front end.
Clinical impression is not diagnosis
You are documenting your professional judgment about functional limitation and the expected response to treatment — not making a medical diagnosis. The generator writes impressions in that register deliberately, because that is the scope of practice for most therapists writing this note.
Questions
Common questions
Does this replace a full standardized assessment?
No. Standardized test scores and specific outcome measures should be entered in the observation field verbatim, which places them in the record exactly as measured.
How long should the initial evaluation note be?
Long enough to justify the plan of care. Detailed is the right setting here — the extra sentences add the baseline and skilled-need language that later notes refer back to.