How To Write Occupational Therapy SOAP Notes (+ 3 Examples)

We get it. Occupational therapy documentation isn’t the most exciting part of your job. But without a solid framework for writing notes, you’ll have trouble tracking client goals and progress, will find it difficult to defend your clinical reasoning, and in most cases—will end up spending way longer on note-taking than is necessary.

Fortunately, if you’re experiencing any of these challenges, there is a solution: Occupational therapy SOAP notes.

SOAP Notes Structure for Occupational Therapy

SOAP notes are a standardized process for clinical documentation that has been widely accepted as best practice by healthcare providers of all types across the globe.[1]

As we explore how to write occupational therapy SOAP notes, keep in mind the dual purpose of the SOAP framework.

Yes, it makes writing notes easier because you have a ready-made structure to follow. But most importantly, SOAP enhances clinical reasoning and decision-making, by ensuring you address all key areas of patient care in each session.

Using Vivek Podder and colleagues’ overview of SOAP notes as a guide, we’ll now start detailing how the SOAP notes structure can be used by OTs.[2]

SOAP enhances clinical reasoning and decision-making, by ensuring you address all key areas of patient care in each session.

Let’s begin with a brief explanation of the four headings of a SOAP note, including SOAP notes examples for your occupational therapy toolkit.

Subjective

Under the first heading of a SOAP note, you’ll list the subjective experiences, feelings, and beliefs of your client or patient.

For example, an OT doing transport training for a person with an acquired brain injury (ABI) might note:

John is a 23-year-old man undertaking physical and cognitive rehab following an ABI six months ago. He recently started transport training with OT to meet his goal of catching the bus independently. Homework prior to the session was for John to plan his route online to catch the bus to a friend’s house later this week. He had a lot of trouble with this task and is feeling very frustrated.

Objective

The objective heading is where you list your assessment of the factors contributing to the patient’s concerns.

Continuing the example above, documentation in the Objective section might include:

When OT attempted to plan the bus route with John, he had a lot of difficulty staying focused on the task and distinguishing which bus routes traveled to his friend’s address.

Analysis

Now that you have your objective data, it’s time to make an assessment.

Under the assessment heading of a SOAP note, revisit your subjective and objective observations to arrive at a diagnosis or analysis of the presenting situation.

John continues to exhibit signs of cognitive impairment evidenced by marked executive dysfunction and impaired concentration. Likely to require additional 1:1 support to make progress on the goal of utilizing public transport independently.

Plan

Finally, end your SOAP note with a plan.

OT to discuss John’s need for additional 1:1 support at the team meeting tomorrow. Will request provision of an OTA/Allied Health Assistant to complete a time-limited supported transport training program. John is agreeable to this plan.

3 Examples for OTs (+ PDF Template)

To see what a full SOAP entry from an OT might look like, we’ve copied the details from the example above into the Activity Builder and session notes feature in the Quenza app.

Patient #1111 DELANEY, Rob

If you prefer to write your notes by hand, here’s a SOAP notes occupational therapy PDF template you can print out for your sessions with patients.

Think of this as your occupational therapy SOAP note cheat sheet!Download this occupational therapy SOAP note template and use it as a guide. Or create your own in minutes using Quenza’s Activity Builder.

Patient #2222 BALANGA, Joy

Here’s another OT SOAP note built with Quenza’s drag-and-drop tools in ten minutes.

Click here to download this OT SOAP Note PDF.

Patient #3333 ELLIS, Alan

If you prefer to keep your documentation organized by client, you can create time- and date-stamped session notes using the SOAP, BIRP, or DAP format in Quenza Notes:

TIP: To document your sessions more efficiently, take a look at our guide and PDF sample notes: How To Write Therapy Progress Notes: 8 Templates & Examples

5 Tips for Writing SOAP Notes

Most OTs find that when they commit to using the SOAP framework for all of their note-taking, the quality of their documentation improves dramatically, and the stress associated with writing notes reduces.

To help you become a master of SOAP notes, here are five tips to help you (and your clients) get the most out of the process:

1. Incorporate client goals. Some therapists find using client goals as an ‘anchor’ for SOAP notes is useful to structure occupational therapy documentation and planning. You might like to include 1-3 of your client’s goals at the top of each note
2. Keep your plans SMART. The SMART framework for goal setting can also be used to improve the quality of your plans; find the framework here: Mental Health Treatment Plans: Everything You Need to Know.
3. You can address more than one issue. The examples above only included one problem in each note, but it won’t always be that straightforward with your patients. It’s completely fine to address more than one issue in an OT SOAP note.
4. Jump around between sections as you write. Compared to free-form note-taking, one of the main benefits of using a template for SOAP notes is you can revisit each section as you write. If you’re writing the plan and forgot to add something under the objective heading, you can simply add it in.
5. Write SOAP notes in session. Where possible, writing SOAP notes in session can improve outcomes because both you and the patient will be guided by the process. The SOAP framework ensures that relevant clinical problems are addressed, along with a coherent plan for the next steps.

Final Thoughts

Using the SOAP notes framework ensures that you always record all important information from each OT therapy session. It also provides a clear process to facilitate high-quality clinical decision-making.

To promote better patient outcomes and reduce the stress and time involved in documentation, you can create your own custom SOAP notes templates in Quenza’s Activity Builder. Then, you can write and store all of your clinical notes in our private, secure, efficient Notes feature.

To get started, sign up for a one-month full-access trial of the Quenza app for only $1.

In addition to Quenza’s Activity Builder and Notes feature, you’ll also get access to HIPAA-compliant tools to help you keep clients engaged between sessions with homework exercises, send psychoeducational content to clients and family members, visually track progress toward goals, and much more.

References