Documentation can be a pretty intimidating class in OT school. But the reality of writing an occupational therapy SOAP note, and other documentation, in the clinic is actually a lot simpler than it sounds.

The main goal of any kind of documentation is to keep a record of the patient’s progress toward their goals and their remaining deficits. This requires the therapist to add interpretations using their clinical lens.

Clinical judgment may sound complicated but, unlike many assignments in OT school, documentation in the real world is intended to be short and to-the-point. This is ideal for the sake of time and productivity, but it’s also the best way to convey the information you need.

A variety of people like administrators, insurance companies, and doctors will look at your notes, and they will not want to sift through too much verbiage to get to what they’re looking for.

Session/treatment notes, also called daily notes since they are completed after each patient visit, are mainly a way to document the activities a therapist does with a patient and how they respond. There are a few styles of writing notes. One is narrative format, which is the norm in mental health or community-based settings.

Some notes are setting-specific. For example, school-based therapists are responsible for writing lengthier progress notes called IEP reports as per a student’s individualized education plan (IEP). Nursing professionals often use SBAR notes, which detail a situation, pertinent background, their assessment, and subsequent recommendations.

The most commonly written note among occupational therapists is the SOAP note. This type of note is similar to the SBAR in that the structure is easy to remember and follows the headings in its name.

A SOAP note consists of the following four components:

S – Subjective

This is where therapists will include information about the patient’s demeanor, mood, or any changes in their medical status. How did the patient seem when you approached them or they arrived for therapy? If patients report any pain, swelling, stiffness, or other symptoms, you will want to include this. This may include new or ongoing symptoms.

You want to be detailed, especially in regards to pain. It’s best to ask the patient to report how intense their pain is using the visual analog scale (VAS), which rates their pain on a scale of 1 to 10. (If patients present to therapy with a lot of pain, it’s a good idea to ask for their levels again later in the session and include this in your SOAP note. This will help document whether certain interventions helped their pain or made it worse.)

O – Objective

Under the Objective heading, therapists will include the activities they did. Unlike the first section, this section is fact-based. It focuses on exactly what you provided to the patient. Some therapists get tripped up with too many details here. It’s more important to include specifics on the skill that each part of the treatment targets rather than exactly what the activity is.

Instead of listing an Uno game that was played, it may be better to say that you led the patient in playing a card game addressing executive functioning and motor planning. This shows the planning and forethought behind the activity, which is the more important part. This is also a good place to add numbers to quantify these skills, when appropriate.

For example, if you are working with a child on a scavenger hunt, it’s good to add that they found 11/13 items. This may also include the amount of time certain activities are completed for, which is helpful if you are working on skills like activity tolerance or sensory integration. For notes that talk about the assist levels (you know: min A, mod A, max A), it is appropriate to integrate these alongside the interventions. But leave the interpretation for the next section!

A – Assessment

This is where all of that OT schooling comes into play. For the Assessment portion, you will use your clinical judgment and reasoning skills to make a determination on the patient’s progress. You can note how the patient tolerated the activity, if they did better on it than they did last time, if they struggled when attempting it, if they completed it with no assistance and you needed to upgrade the task, etc.

You don’t always need to go through each activity you did one-by-one and make your interpretation unless it’s very relevant to know. It’s a good idea to add a general summary of their progress during that session. This is also a good preparation for what you’ll write in the next section.

P – Plan

As a good end to the note, the Plan section helps inform your actions during the next session. Sometimes it’s just a general statement such as: “Continue goals outlined in the plan of care as tolerated.” But other times, it may be helpful to make a remark about what you assigned for the patient’s home exercise program, tasks you’d like to upgrade or downgrade next time, modifications that may help the patient’s tolerance or progress, and more.

There are several guidelines that all therapists should follow when taking notes, regardless of the type of note they write.

4 Things To Remember With SOAP Notes

Occupational therapy SOAP notes don’t have to be separated

For the purposes of learning activities, your professors may make you indicate what you put under the S, O, A, and P sections. But this isn’t necessary for notes in the clinic.

The SOAP note should naturally go from one part to the next. Don’t stress about making it sound just right, since the flow reflects the natural progression of a treatment session. So you will be doing just fine by simply writing about things in the order they happened.

Healthcare staff must be able to understand them

Notes don’t necessarily have to be understood by the general public, even though they are able to request notes for their own reference. But other medical professionals should be able to interpret them easily. This means that you must use universal abbreviations.

There are a whole slew of these, such as BUE meaning bilateral upper extremity and ROM meaning range of motion. For more approved abbreviations to use in documentation, be sure to check out our other article, The Must-Know Occupational Therapy Medical Abbreviations.

Therapists must be able to replicate your treatments

Similarly, other therapists should be able to use your notes to replicate treatments. This doesn’t mean you need to write down all the specifics of each activity you did with a patient. But you should note the important parts. An example is: “Upgraded ring toss activity focused on dynamic standing balance and visual tracking without external support” rather than “ring toss in standing.”

If you are doing something a bit more detailed such as making splints or applying kinesiotape, you should include specific measurements, dimensions, tape placement, strap fitting, etc. These figures are highly variable from person to person and it often takes therapists multiple sessions to make appropriate adjustments that are a good fit for the patient.

All notes must show medical necessity

Documentation must demonstrate medical necessity at all points. If you don’t know what medical necessity is, it refers to the reason why someone continues to need skilled services. So all of a therapist’s notes must indicate patient deficits that are severe or impactful enough to require continued OT treatment. This not only helps contribute to the reputation of our profession, but it ensures that patients will receive insurance reimbursement for the care they get.

Now let’s put everything together.

Here is an example of a well-worded, but brief occupational therapy SOAP note example for a patient receiving OT in a skilled nursing facility. Again, we are outlining the separate sections for reference purposes. But remember, a good OT SOAP note will be written as one note that is about a paragraph!

S: Israel was approached for OT while in his room with his daughter present. He had just been toileted by CNA and reported he is “feeling better now.” He was motivated to try lower body dressing today.

O: Israel needed mod A x2 to sit EOB for dressing training. He needed CGA to don UB clothing. With 2-3 tactile cues for dynamic balance, he was able to don pants with min A. OT educated Israel on use of sock aid. He completed 3 trials with min/mod A and reported it was “harder than he thought.”

A: Israel demo’d good safety awareness in holding the bed rails for stabilization. He retained training on UB dressing sequence from last session. Endurance for dressing tasks appears to have improved. O2 sats remained stable throughout session and he was noted to use pursed lip breathing appropriately.

P: OT educated daughter on transfer training and pursed lip breathing techniques for use at home and also provided handout. OT to discuss potential co-treat with PT for next session. Continue goals per POC as tolerated.

_____________

As you can see, occupational therapy documentation is as simple as recording what happens and adding your clinical judgment to it. Don’t over-complicate things, and make it clear enough for any therapist to replicate.

Practice makes perfect, so take advantage of opportunities that will let you turn scenarios into notes. This will help you master documentation in no time!

What do you think is the most difficult part of documenting occupational therapy SOAP notes? Do you have another type of treatment note that you prefer? Let us know in the comments.

This post was originally published on July 6, 2021 and updated on May 16, 2023.