Occupational Therapy Soap Notes – Tips and Tricks for Beginners

If you are an occupational therapist, then you might often wonder that SOAP notes are the gold standard when it comes to evaluating the progress of clients. 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.

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

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

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 is used by the occupational therapist in different clinical settings.

How important are occupational therapy soap notes?

Tips to write SOAP Notes
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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 client was engaged along with their response.

Make sure that you include all information 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 plan of care of the client.

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 notes 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, you might have a question that how to document it? You can use different paper templates or an EHR software in order to process the therapy function notes. TheraPlatform for instance is inclusive of different practices and it is also HIPAA-compliant. There are different templates available which can be customized according to the needs of occupational therapist.

Occupational therapy soap notes examples

Occupational therapy soap notes examples
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Subjective: One of the client was dropped off by their parents for the purpose of attending the occupational therapy session. According to the client’s parents, the client is positively responding towards 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 was able to complete their task that includes tying shoes, washing hands along with simplified cues for sequencing. In addition, for doing these task, client required minimal assistance from the therapist and was able to attempt the task on his own. This can be a good self-regulation from the client 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.

A Take-Home Message

Based on the discussion presented above, you can see that occupational therapy soap notes 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!