{"id":17241,"date":"2023-02-12T22:39:21","date_gmt":"2023-02-12T22:39:21","guid":{"rendered":"https:\/\/quenza.com\/blog\/?p=17241"},"modified":"2025-06-21T10:22:10","modified_gmt":"2025-06-21T10:22:10","slug":"occupational-therapy-soap-note","status":"publish","type":"post","link":"https:\/\/quenza.com\/blog\/occupational-therapy-soap-note\/","title":{"rendered":"How To Write Occupational Therapy SOAP Notes (+ 3 Examples)"},"content":{"rendered":"\n

We get it. Occupational therapy documentation isn\u2019t the most exciting part of your job. But without a solid framework for writing notes, you\u2019ll have trouble tracking client goals and progress, will find it difficult to defend your clinical reasoning, and in most cases\u2014will end up spending way longer on note-taking than is necessary.<\/p>\n\n\n\n

Fortunately, if you\u2019re experiencing any of these challenges, there is a solution: Occupational therapy SOAP notes.<\/p>\n\n\n\n

SOAP Notes Structure for Occupational Therapy<\/h2>\n\n\n\n

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.<\/p>\n\n\n\n

As we explore how to write occupational therapy SOAP notes, keep in mind the dual purpose of the SOAP framework.<\/p>\n\n\n\n

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.<\/p>\n\n\n\n

Using Vivek Podder and colleagues\u2019 overview of SOAP notes<\/a> <\/strong>as a guide, we\u2019ll now start detailing how the SOAP notes structure can be used by OTs.<\/p>\n\n\n\n

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SOAP enhances clinical reasoning and decision-making, by ensuring you address all key areas of patient care in each session.<\/p>\n<\/blockquote>\n\n\n\n

Let\u2019s begin with a brief explanation of the four headings of a SOAP note, including SOAP notes examples for your occupational therapy toolkit<\/a><\/strong>.<\/p>\n\n\n\n

Subjective<\/h3>\n\n\n\n

Under the first heading of a SOAP note, you\u2019ll list the subjective experiences, feelings, and beliefs of your client or patient.<\/p>\n\n\n\n

For example, an OT doing transport training for a person with an acquired brain injury (ABI) might note:<\/p>\n\n\n\n

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.<\/em><\/p>\n\n\n\n

Objective<\/h3>\n\n\n\n

The objective heading is where you list your assessment of the factors contributing to the patient\u2019s concerns.<\/p>\n\n\n\n

Continuing the example above, documentation in the Objective section might include:<\/p>\n\n\n\n

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\u2019s address.<\/em><\/p>\n\n\n\n

Analysis<\/h3>\n\n\n\n

Now that you have your objective data, it\u2019s time to make an assessment.<\/p>\n\n\n\n

Under the assessment heading of a SOAP note<\/a><\/strong>, revisit your subjective and objective observations to arrive at a diagnosis or analysis of the presenting situation.<\/p>\n\n\n\n

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.<\/em><\/p>\n\n\n\n

Plan<\/h3>\n\n\n\n

Finally, end your SOAP note with a plan.<\/p>\n\n\n\n

OT to discuss John\u2019s 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.<\/em><\/p>\n\n\n\t

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