A SOAP note is a standardized, four-part format (Subjective, Objective, Assessment, and Plan) used for clinical documentation across many healthcare professions, including occupational therapy. This structured approach provides a systematic way for therapists to record the details of a patient’s session and track their progress over time. Effective documentation through SOAP notes is required to maintain legal and ethical standards, facilitate communication among the healthcare team, and support the justification for skilled services for proper reimbursement. These notes create a chronological record of the client’s status, interventions provided, and response to treatment, making them a fundamental tool for planning and adjusting care.
Capturing Subjective Information
The Subjective (S) section captures the client’s perspective, including information reported by the client or their family regarding their condition, feelings, and perception of performance in daily activities. It is effective to use direct quotes from the client to capture their voice and specific concerns, especially regarding pain levels, fatigue, or barriers to participation in meaningful occupations.
The information recorded must be relevant to the session or the client’s current functional status. For instance, document a client’s reported pain level (e.g., 7/10 on the Visual Analog Scale) and their statements about how this pain limits a specific task, such as preparing a meal. Also include the client’s self-reported goals, expectations, and any changes in their condition since the previous session.
Documenting Objective Data and Services Provided
The Objective (O) section focuses on verifiable, measurable, and observable data gathered by the therapist during the treatment session, excluding personal opinions or interpretations. This section provides the factual evidence that justifies the skilled nature of the occupational therapy intervention. It typically begins by stating the setting, the duration of the session, and the specific activities the client participated in.
Documenting the specifics of the intervention involves detailing the activities performed, such as practicing a dressing task or engaging in a cognitive exercise like meal planning. The therapist must record the client’s performance level and the type of assistance provided, using standardized terminology like “minimal assist,” “standby assist,” or “verbal cues” for a specific task. For example, the note might state, “Client required minimal assistance to don a shirt due to difficulty manipulating buttons.”
Quantitative data is essential for demonstrating progress and medical necessity, including physical measurements and standardized test results. The therapist should record specific metrics, such as goniometric measurements for range of motion, manual muscle testing scores (e.g., 3/5 strength), or the time taken to complete a functional task. Precise documentation of performance, such as “Client completed 10 repetitions of shoulder flexion at 75% maximum resistance,” provides an accurate baseline for tracking future improvement. The objective description should also capture the client’s observable behavior and response to the intervention.
Developing the Professional Assessment
The Assessment (A) section synthesizes the information from the Subjective and Objective sections to provide the therapist’s professional interpretation and clinical reasoning. The therapist analyzes the data, explaining the meaning of the client’s subjective complaints and objective performance. The core purpose of this section is to justify the need for ongoing skilled occupational therapy services by demonstrating the complexity of the client’s needs.
The analysis must identify the underlying limiting factors contributing to occupational performance deficits, such as strength deficits, impaired fine motor coordination, or cognitive impairment. The therapist should comment on the client’s progress toward established goals, noting any improvements, plateaus, or setbacks observed during the session. A concluding statement regarding the client’s potential for future improvement, known as the prognosis, is also included, providing an outlook on recovery based on the data and clinical judgment.
Outlining the Treatment Plan
The Plan (P) section concludes the SOAP note and details the specific actions the therapist will take to help the client achieve their goals. This section ensures continuity of care by outlining the frequency and duration of future occupational therapy sessions, such as “Continue OT 2 times per week for the next four weeks.” It must specify the interventions that will be continued, modified, or introduced, focusing on how the plan will address the limiting factors identified in the Assessment.
Specific details about the updated treatment approach are included, such as modifying therapeutic activities to increase the challenge or introducing a new preparatory task like heat application. The Plan also documents instructions for the client’s Home Exercise Program (HEP), including the exercises, repetitions, and frequency, or any updated short-term goals. Finally, this section records any necessary communication or referrals needed to coordinate the client’s care.