Occupational Therapy Business Tips

How To Write Occupational Therapy SOAP Notes

updated on

February 16, 2024

A lady writing ot documentation

Occupational therapy SOAP Notes are a necessary, albeit time-consuming, part of treatment. The secret to writing effective SOAP notes is to be clear and concise. When you’re pressed for time between clients or visiting patients at home, that may feel easier said than done. That’s why it’s important to have a system and to automate as much of the process as possible. You’ll learn how to do that in this article.

How To Write Occupational Therapy SOAP Notes

Use a SOAP Note template to document treatment details quickly. Your occupational therapy SOAP notes template should have 4 sections: Subjective, Objective, Assessment, and Plan. Keep SOAP notes simple and get straight to the point. This makes documentation scannable and easy for you and other healthcare providers to understand.

When you’re writing occupational therapy SOAP notes, the goal is to communicate the client’s status and treatment clearly. Effective SOAP notes allow another OT to take over and replicate the treatment if need be. They also convey important information to other healthcare providers. Keep it as brief as possible. Include essential details of client’s status, symptoms, progress, skills worked on, and treatment plan.

Here’s a breakdown of what to information to put in each section of occupational therapy SOAP notes:


Record what the client, or the client’s caregiver, reports to you about the client. These details aren’t necessarily facts, but rather a recounting of the client's feelings or reported progress. Subjective notes may include things like:

  • Client’s mood or demeanor
  • Changes in medical status (that you have not yet confirmed with their doctor)
  • Pain client is experiencing
  • Progress reported since your last session
  • Client’s or caregivers concerns


This is where you document factual information. This may include treatment details, your observations, modalities and interventions applied, and measurable results. Focus your notes more on the skills you’re working on vs the specifics of the activities performed. Objective notes include things like:

  • How much assistance they needed
  • The way you modified their environment or an activity
  • How they performed and level of success
  • How they responded to your interventions
  • The reason you chose a specific modality


Report your clinical reasoning here. Analyze the subjective and objective information, and state your conclusions here. This may include things like:

  • How the client did during their session
  • How they are progressing towards their occupational therapy goals


List your plans for their next therapy session in this section. Plans may include:

  • Necessary changes to the treatment strategy in terms of activity or frequency
  • Modifications needed
  • Referrals or recommendations

Examples of SOAP Notes for Occupational Therapy

Here are some examples of documentation for occupational therapists, we recommend using occupational therapy software to track your documentation, and manage client health history forms and files.

occupational therapy SOAP notes


The client, a 68-year-old female, reports feeling frustrated with her limited mobility and difficulty performing daily activities. She expresses a desire to improve her independence and quality of life.


  • Vital signs: blood pressure 120/80, heart rate 80 bpm, respiratory rate 16 bpm, temperature 98.6°F
  • Observation: client presents with hemiparesis on the left side, decreased grip strength, and difficulty with fine motor tasks such as buttoning clothing
  • Range of motion (ROM): left shoulder flexion 50°, left elbow flexion 60°, left wrist extension 20°
  • Functional Independence Measure (FIM): Total score of 85/126, with a score of 2 for all self-care tasks on the left side


The client is a stroke survivor with hemiparesis on the left side, decreased grip strength, and difficulty with fine motor tasks. She reports frustration with her limited mobility and desire to improve her independence and quality of life. Her ROM and FIM scores indicate moderate impairment and dependence with self-care tasks on the left side.


  • Continue with current occupational therapy interventions, including range of motion exercises and functional activities to improve left-sided strength and coordination
  • Incorporate adaptive equipment and environmental modifications to facilitate independence with daily activities, such as a button hook for clothing and a shower chair for bathing
  • Provide education to the client and family members regarding stroke recovery, including the importance of ongoing therapy and strategies to prevent future strokes.

How Should I Document Goals as an OT?

Documenting goals as an OT is a critical part of therapy. Goals should be clear, measurable, and achievable. Record occupational therapy goals in SOAP notes. Measure progress towards goals in the objective section of your notes. Re-evaluate goals in the assessment section, and document needed changes in the plan section.

Goals help guide your treatment plan and provide a framework for measuring progress and success. Here are 4 best practices for goal setting:

1. Collaborate with the Client

First, find out what the client wants to achieve. Create goals that are relevant and meaningful to their life.

2. Use the SMART Framework

Using this framework helps ensure that goals are focused, well-defined, and achievable within a specific timeframe. SMART stands for: Specific, Measurable, Achievable, Relevant, and Timely.
Document SMART goals in your SOAP notes.

3. Use Objective Measures

Objective measures help track client progress. These measures include things like assessments, standardized tests, and observation of functional tasks. Documenting objective measures in SOAP notes provides a clear record of progress, which is useful for communicating with other healthcare professionals.

4. Review and Re-evaluate Goals

Review goals regularly to ensure that they are still relevant, achievable, and meaningful to the client. If a goal is not being met or if the client's priorities have changed, re-evaluate and adjust the goal. Document these goal reviews and changes in your SOAP notes to track treatment progression.

smart goals of documentation

How To Write A Discharge Note as an OT

A discharge note documents the progress the client made during therapy, goals they achieved, and recommendations for future care. It’s important to be clear, concise, and comprehensive when writing a discharge note. This will ensure the client’s care continues on, as intended, after their therapy has ended.

Here are some best practices for writing a discharge note as an OT:

1. Summarize Progress

A summary of progress is a good reference for reviewing a client’s journey. Provide specific examples of progress to demonstrate the effectiveness of their therapy. Also include objective measures and any functional gains that were made.

2. Outline Goals Achieved

Specify which goals were met and how they were achieved. Outlining these details gives clients and healthcare providers a clear understanding of progress that’s been made in therapy.

3. Provide Recommendations

Provide recommendations for future care including referrals to other healthcare professionals, recommendations for continued therapy, and suggestions for on-going care. Also include information about follow-up appointments and your contact information.

Software Can Streamline Occupational Therapy SOAP Notes

Using customizable SOAP notes software with integrated intake forms makes the documentation process extremely efficient. There’s no need for paper files. You can record notes on whatever device is most convenient for your practice. That might be sitting at your desk in the clinic, or on a tablet in your client’s home.

When you use software to create SOAP notes, you can access all your client records with just a touch of a button. Customize forms to your style of documentation to make the writing process quick and simple. 

When you use software, you have the notes you need, no matter where you are. It saves time and space. Most importantly, you’ll have clean and organized occupational therapy SOAP notes to review and share with other providers.

Free OT documentation template
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