SOAP Note

purpose of a SOAP note

provides a clear, organized, and standardized way for healthcare professionals-including OTs to document a client’s status, progress, and plan of care

what is the most common documentation framework

SOAP notes

S=

subjective- what the family or patient reports

things to keep in mind about S

client’s report of limitations and problems, as well as what the client said that is relavent

O =

objective (measurable, re-producable, observations related to performance, level of assistance, etc)

O importantce

it must present a picture of the skilled session

A =

assessment- interpretation of the situation, safety issue, rehab potential

A significance

appraisal of the clients performanace and benefit from OT services based on S and O sections

P=

what the OT plans to do next

P significance

anticipated frequency and duration of services and the specific interventions that will be used to achieved goals.