Fieldwork Chapter 8
SOAP Notes— SUBJECTIVE
subjective information
information obtained from the client that is their POV on their condition or treatment
usually cannot be verified or measured during the treatment session
client’s report of limitations, concerns, problems, complaints, fatigue, expressions of feelings, attitudes, concerns, goals, plans
often direct quotes
sometimes is acceptable to report comments from caregivers or other professionals if the comments are directly related to OT services
examples
“I don’t need therapy.”
“I can’t wash the dishes or zip my coat.”
Pt asked for help when it was needed during the session.
Pt reports he feels “pretty good” and his goal is to “get back as independent as I can.”
Client did not speak without cueing.
in the evaluation note, the S may contain some or all of the client’s OT profile
common errors
most common error is not communicating with clients enough during sessions
keeping conversations related to therapy instead of small talk is important for documentation
directly quoting the client without going into any details and not summarizing in a concise and coherent way
there is no reason to repeat the client’s history in the S when it is available in other sections of the client’s health record
this is the space to report something the client said or otherwise communicated during the session