How to Write SOAP Notes for OTs (with Examples)
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Whether you call them “daily notes,” “session notes,” or “treatment notes,” SOAP notes are the gold standard when it comes to documenting a client’s progress for occupational therapists.
What is a SOAP note?
A SOAP note is a standardized note format that provides a detailed description of how a client did during their session, as well as the occupational therapist’s observations and plans for the client moving forward. SOAP stands for Subjective, Objective, Assessment, and Plan and are used by occupational therapists everywhere.
Why are SOAP notes important for occupational therapists?
SOAP notes are important for occupational therapists for a number of reasons. There’s a common saying in the medical field—especially among occupational therapists—when it comes to documenting a client’s progress: “if you didn’t document it, it didn’t happen.”
These notes provide a standardized way to take notes during your occupational therapy sessions that is not only objective, but concise. Because SOAP notes follow a specific format, they are familiar to other therapists as well as any clinician in the health and wellness field. This is especially beneficial for interdisciplinary practices so all members of the team can clearly see what the client has been working on and appropriate next steps.
How to write a SOAP note
When you write a SOAP note as an occupational therapist, you need to follow the SOAP acronym. If you’re writing SOAP notes by hand, it’s helpful to have a printed template with boxes for each section that are easy to fill in. If you use an EMR to document SOAP notes, chances are there’s an integrated template within your software to ensure your notes are accurate and follow the standardized format.
What information should be in an occupational therapy SOAP note?
The information that you put in a SOAP note will vary depending on many factors. The actual SOAP note format will always be the same, but the content for each section is dependent on the setting of your work, clients you see, and more.
We’ve broken down the order of how you should write a SOAP note for occupational therapy, and what should (and shouldn’t) be included.
S – Subjective
This section is for subjective reporting of your client and their concerns or questions. It can include:
- Client’s mood
- How a client is feeling that day
- Questions your client asked
- Another person’s report of the client’s mood, behavior, or progress (such as a teacher, parent, family member, or other medical professional).
It’s important to note that any information included in this section is not passed off as fact. For example, if your client comes in and says, “my doctor stated that I have to get a knee replacement” is not actually a fact until you confirm with their doctor.
O – Objective
The objective section should be made up of quantitative, factual, and measurable data. This includes your observations of the client, any specific interventions or modalities used in the session, and your client’s response to them. Make sure to include:
- Observations of how the client is performing in a specific task
- How the client is performing throughout their occupational therapy session
- Details about specific interventions or therapeutic activities the client engaged in and their response
Make sure to include information about why you chose a specific intervention or therapeutic activity for a client and how it relates to the client’s occupational therapy goals and plan of care.
A – Assessment
The assessment section is where you document your analysis and interpretation as an occupational therapist of both the subjective and objective information, specifically looking at:
- How the client did during their session
- The client’s progress toward their occupational therapy goals
P – Plan
This last section of your SOAP note should provide insight into your plan with the client moving forward. The plan section is also where you can state anything you are changing in their future occupational therapy sessions, such as:
- Therapeutic activities
- Objectives
- Therapy frequency
SOAP note examples for occupational therapists
We’ve created some SOAP note examples for occupational therapists below. As mentioned before, the content for each note will depend on a few different factors, but the format of the SOAP note will always stay the same.
SOAP note example for a pediatric client at a outpatient clinic
- Subjective: Client was dropped off by their parents for their occupational therapy session today. Client’s parents report that client is responding positively to their sensory diet at home. Client requested to use the sensory gym at the end of their session.
- Objective: During the session, the client was able to complete ADL tasks including donning socks, tying shoes, and washing hands, with moderate verbal cues for sequencing. Client required minimal assistance to zip up a zipper on a jacket laid flat on a table due to decreased fine motor coordination and strength. Client transitioned independently to the sensory gym and engaged in linear swinging on the platform swing and stated “this is good for my self regulation”
- Assessment: Client demonstrated increased frustration tolerance today when working on zipping up a zipper that was laid flat on a table and did not quit the task or throw his jacket. Client demonstrated progress with requesting sensory gym independently when they were starting to feel disregulated.
- Plan: Client will complete ADL tasks including donning socks, tying shoes, and washing hands independently in their home environment. Continue with the current plan of care for increasing the client’s independence with ADLs and self regulation.
SOAP note example for an adult client in a skilled nursing facility
- Subjective: Client was awake when occupational therapist entered their room at their scheduled appointment time. Client stated they didn’t sleep well and had been up for 3 hours, but was going to try their best in occupational therapy today. Client requested to work on their tooth brushing today.
- Objective: Therapist retrieved client’s toothbrush and toothpaste for client. Client required moderate assistance to open toothpaste lid and squeeze toothpaste onto the toothbrush due to decreased fine motor coordination and strength. Once client’s toothbrush was set up they were able to brush their teeth with moderate verbal cues secondary to decreased sequencing. Client’s nurse entered the client’s room as they were finishing up brushing their teeth to take them to the nurse’s station for their medication.
- Assessment: Client demonstrated increased engagement in their occupational therapy session despite being tired. Client was noted to make improvements with only requiring moderate assistance for toothbrushing set up.
- Plan: Continue with client’s occupational therapy plan of care focusing on increasing client’s independence with ADLs in anticipation of client’s discharge to their family home in 1 month.
SOAP note example for a adult client in a inpatient rehab setting
- Subjective: Client stated they are still feeling a lot of pain after their hip surgery, and rated their current pain at rest as a 7/10—10 being the most pain. Client stated that their nurse is going to increase their pain medication dosage.
- Objective: Client was able to sit on the edge of a raised mat and practice donning a sock with a sock aid. Client was able to don a sock x2 with modified independence with a sock aid. Therapist reviewed client’s hip precautions with client and client was able to recite them back correctly x3 during therapy today. Therapist instructed client on how to don pants using a long handled reacher and client required moderate assistance to don pants x2 using long handled reacher due to decreased upper extremity strength and increased pain.
- Assessment: Client demonstrated good engagement in their occupational therapy session today despite having increased pain as a result of their recent hip surgery. Client was noted to understand and follow hip precautions and put on socks using a sock aid while following hip precautions.
- Plan: Client will complete all aspects of ADLs while following hip precautions. Continue occupational therapy Plan of Care.
How to use SOAP notes with your EMR
To use SOAP notes with your EMR, it’s essential to make sure it has the features you need to help save you time. SOAP notes—and other documentation—are typically the most time consuming part of an occupational therapist’s day.
Top-rated EMRs with integrated SOAP notes will let you:
- Customize the SOAP note
- Load a previous note
- Create new notes from scratch
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