Occupational Therapy Soap Notes – Tips and Tricks for Beginners

occupational therapy soap notes

If you are an occupational therapist, you might often wonder that SOAP notes are the gold standard when evaluating clients’ progress. Regardless of the nature of the client, you will think about whether to call them session notes, or treatment notes.

For an occupational therapist, documentation can be a pretty daunting task, however, the reality of writing occupational therapy soap notes in the clinical setting is actually a lot simpler than it sounds. The ultimate goal of any sort of documentation in the clinical setting is to keep a record of the patient progress in terms of the diagnosis and treatment. From a therapist’s perspective, he or she can add interpretations to the diagnostics using the clinical lens.

 occupational therapy

The clinical judgment regarding patients may sound difficult but unlike different OT school assignments, the patient’s documentation needs to be on point. This is why it is ideal for saving productivity and time, and it is also an effective way to convey the required information.

Let’s dig into the concept of SOAP notes and how the occupational therapist uses it.

What is meant by a SOAP note?

A SOAP note is explained as a set of documentation which aims to provide a detailed description of what the client did during their session, also the occupational therapists plans and observations for the client to move forward. The abbreviation for SOAP note stands for Subjective, Objective, Assessment, and Plan, which the occupational therapist uses in different clinical settings.

How important are occupational therapy soap note?

Tips to write SOAP Notes

Occupational therapists should take SOAP notes for a variety of reasons. When it comes to tracking a patient’s progress, occupational therapists in particular have a statement that is often used in the medical community: “if you didn’t document it, it didn’t happen.”

These notes offer a consistent, clear, and objective manner to record information from your occupational therapy sessions. Since SOAP notes adhere to a set structure, they are known to all clinicians working in the health and wellness industry as well as other therapists. This is especially useful for interdisciplinary firms so that every team member can see exactly what the client has been working on and what the best course of action is.

S – Subjective

This section of the Soap note is based on the subjective reporting of the client along with their questions or concerns. Moreover, this can majorly include,

  • The mood of the client
  • How a client is feeling on the particular day
  • Type of questions asked by the client
  • Report related to client’s behavior or progress

It is necessary to note that the information which is included in this section is not passed out of the fact. For instance, if a occupational therapist client comes in and utters, “I got suggested by my doctor to have a knee transplant” which is actually not the fact until you get confirmation from the doctor.

Also Read: How Long Does Credentialing Take?

O – Objective

The objective section of the soap notes is the most important one as it is made up of factual, measurable and quantitative information. This includes a set of your observations related to the client, along with any specific modalities or interventions used for the session and how your client is responding to it. You are required to make sure to include the following:

  • Observations related to how the client is performing a certain task
  • How the client has behaved throughout the session of the occupational therapy?
  • Tiniest details associated with the specific interventions or the therapeutic activities in which the client was engaged and their response.

Make sure that you include all information on how you have selected the specific intervention or a related therapeutic activity for the client, which is eventually contributing the therapy goals along with the client’s plan of care.

A – Assessment

After having jotted down subjective and objective points, there comes the assessment of the client in which you document the analysis along with the interpretation being an occupation therapist in terms of both objective and subjective information while looking at the aspects such as,

  • How the client responded during the occupational therapy session?
  • The overall progress of the client towards the occupational therapy goals.

P – Plan

Here comes the last section of the occupational therapy soap note, which provides an insight to your plan with the client and a course of action to move forward. In this planning, you can highlight anything in terms of upcoming occupational therapy sessions such as,

  • Objectives
  • Therapy frequency
  • Therapeutic activities

How to write a SOAP note for an occupational therapist?

Now you have complete background knowledge about occupational therapy soap notes and might have a question about how to document them. You can use different paper templates or EHR software to process the therapy function notes. TheraPlatform, for instance, includes different practices and is also HIPAA-compliant. Different templates are available that can be customized according to the needs of an occupational therapist.

Occupational therapy soap note examples

Occupational therapy soap notes examples

Subjective: One of the clients was dropped off by their parents to attend the occupational therapy session. According to the client’s parents, the client positively responds to intermittent diet at home. Now, the client has requested to use their fitness gym at the end of the therapy session.

Objective: Within the therapy session, the client completed their task, which included tying shoes and washing hands, along with simplified cues for sequencing. In addition, the client required minimal assistance from the therapist to do these tasks and could attempt the task independently. This can be a good self-regulation from the client’s perspective.

Assessment:  Client is progressing since he requested for a gym session independently after the therapy session. This might be a sign of increased tolerance and less dependence on the therapist.

Plan: Client will continue to complete the ADL task which includes tying shoes, donning socks and washing hands on their own in their home environment. He will be under the surveillance of the parents. If there is a positive sign, then we can continue with the current plan of care for the client and increase the independence on self-regulation.

Benefits of Occupational Therapy SOAP Notes

There are several benefits to using SOAP notes in occupational therapy:

Organized documentation: SOAP notes provide a structured framework for documenting patient information, making it easy to organize and access information when needed.

Objective tracking of progress: By documenting objective information in the objective section of the note, such as measurable changes in the range of motion or strength, therapists can track the patient’s progress over time.

Improved communication: SOAP notes can be used to communicate patient information to other healthcare professionals involved in the patient’s care, ensuring that everyone is on the same page and working towards the same goals.

Legal protection: SOAP notes serve as a legal record of patient care, providing evidence of the therapist’s actions and decisions in the event of a malpractice claim or legal dispute.

Increased efficiency: SOAP notes allow therapists to quickly and efficiently document patient information, freeing up time for more direct patient care and improving overall productivity.

A Take-Home Message

Based on the discussion presented above, you can see that occupational therapy soap note is a simple documentation task and it is entirely based on the expertise of occupational therapists and their clinical judgments. Hence, it is a simple task and it is better to make it transparent for the client about the plan of action. Indeed, practice makes things perfect, so it is necessary to take advantage of opportunities and design the most effective soap notes. All the best!