Overview Of Occupational Therapy SOAP Notes

S-Subjective
First section of the SOAP note, Contains subjective information obtained from the patient, The patient’s perspective on his or her condition or treatment, Document what the patient said regarding complaints of pain fatigue concerns goals feelings
Key Points For Subjective
You can quote or summarize what the patient said, Be specific rather than general, Statements cannot be verified or measured, Write concise coherent statements, Make good use of communication time with patient
Examples Of Subjective
“I can’t wash the dishes or zip my coat,” Patient reports of pain in right shoulder when putting away drinking glasses from the dishwasher, “I don’t need therapy,” “I feel relief that I am here in this rehab facility.”
O-Objective
Second section of the SOAP note, Contains all measurable quantifiable observable data obtained from treatment, Length of treatment (time) may also be required, This is where you present a picture of the treatment that you have observed
Key Points For Objective Part 1
Can write it chronologically or organize it into categories, Focus on the patient’s response to the treatment provided, Write from the patient’s point of view, Clearly state that you were not just a passive observer in the treatment session, Be professional and concise
Key Points For Objective Part 2
Focus on function, Use only standard abbreviations, Be specific about assist levels, Focus on performance components
A-Assessment
Third section of the SOAP note, Contains the therapist’s opinion or judgment regarding the client’s progress functional limitations expected benefit from rehabilitation, This is where you will interpret the meaning of the data you have presented in the objective session describing what is the means professionally and its potential impact on the patient’s occupational performance
Assessment Note The 3 P’s
Problems, Progress, Rehab Potential, You may also point out inconsistencies, Discuss emotional components, Discuss variation from planned activities to treatment
Key Points For Assessment
You will need to read over the subjective and objective and make list of significant areas to discuss in the assessment section of your note, This is not a section for new information, Justifying continued treatment
P-Plan
The fourth section of the SOAP note, Contains the specific treatment the patient will receive to achieve the goals, The “p” should relate to the information presented in the assessment, This section informs the reader what you plan to do next in treatment
Key Points For Plan
You will address how often you will see the patient, How long the treatment will continue, Set your priorities for what you will work on next, Goals will be written in this section, Goals are always written in measurable objective behavioral terms, Goals include a function and time line
Summary
Documentation is necessary, Develop skills at school fieldwork on the job over time, Your professional responsibility to accurately document the OT process in a timely manner and to improve on your skills over time