SOAP notes

S in SOAP

Subjective: how the client feels about therapy/how engaged they are.

direct quotes are best

Provide an example of subjective in SOAP note

“I’m so glad we did that (ADL) today, it was harder than I expected”

“pt somewhat agitated (raising voice and cussing) however PT was able to be redirected to intermittent active participation in grooming tasks when presented with rest breaks in between tasks”

O in SOAP

Objective: what the client did, where they did and how they did it (SCORE)

Provide example of O in SOAP note

“pt seen for OT services, while in supine in bed upon OT arrival. Pt able to complete bed mobility, transitioning from supine to EOB with mod A for managing LE with task. Pt able to stand from bed with mod A and ambulates usiing RW to bathroom with CGA. Pt stands for toileting and completes toileting task with CGA and min cues for safety awareness.”

A in SOAP

Assessment: describe why client needs OT; what do they do well and what do they need assistance with

Example of A in SOAP

“Pt has good safety awareness and can maintain his weight bearing precautions of L LE with minimal cueing. Pt’s mobility restrictions, difficulty adapting tasks safely and pain of L hip and lower back results in decrease I with standing ADL tasks, functional transfers and IADL performance.”

P in SOAP

Plan: clearly illustrates a care plan that relates to the assessment of the client’s performance and the client’s goals.

Example of P in SOAP

“Pt should continue with skilled occupational therapy services for 1 hour per day. 5x/week for 2 weeks to address ADL and IADL performance deficits.”

Education aspect of SOAP

clearly explains who engaged in the learning experience (client, caregiver, therapist) and how they responded (demonstrated return of learning, ongoing education needed)

Example of Education

“Client educated about safety techniques when using walker throughout the session, demonstrates difficulty returning learning. Continue to address safety training with pt and caregiver(s)”