Writing the Assessment (A) Section of a SOAP note

Clinical reasoning and synthesizing information

What are the key components of the “A” section?

Analysis (interpreting the significant of collected data)

Prioritization (Indentifying the most critical issues affecting the client’s occupational performance)

Connection to goals (linking assessment findings to established therapy goals

**these all involve clinical reasoning**

What are the 4 types of clinical reasoning in OT assessments?

Scientific, Narrative, Pragmatic and Ethical

What is a scientific clinical reasoning assessment?

Evidence-based and clinical knowledge (focus on facts, such as impairments, disabilities, and performance contexts)

(using evidence based protocols to treat a client with a specific diagnosis)

What is a narrative clinical reasoning assessment?

Understanding the client’s story (involves understanding the client’s personal story and experiences)

Ex: consider a client’s role as a parent when planning interventions

What is a pragmatic clinical reasoning assessment?

Practical considerations (considers the moral aspects of care, ensuring decisions align with professional standards

Ex: Respecting a client’s decision to decline a particular intervention

What is an ethical clinical reasoning assessment?

Aligning with professional standards (considers the moral aspects of care, ensuring decisions align with professional standards

Ex: Respecting a client’s decision to decline a particular intervention

How does the Subjective (S) and objective (O) data support each other?

Subjective Data = Patient-reported information (i.e. pain levels)

Objective Data = Measurable observations (i.e range of motion)

Combining data to identify patterns and justify goals

S: Client reports fatigue during ADLs

O: Decreased endurance observed during 6-minute walk test (completed 50% of expected distance of 40 feet)

A: The client’s reduced endurance impacts their ability to perform ADLs such as cooking and grooming

What are the 3Ps in your assessment?

Problems, Progress, and Potential

What are “problems” in your assessment?

Safety risks

Inconsistencies between client report and objective findings

Contributing factors that can be influenced by OT intervention

What is the “progress” in your assessment?

Is OT intervention effective

Is there progress within a single session or as compared to a previous session

Is there a lack of progress

What is a “potential” in your assessment?

What is client’s potential for future improvements