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.
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.
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:
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:
Report your clinical reasoning here. Analyze the subjective and objective information, and state your conclusions here. This may include things like:
List your plans for their next therapy session in this section. Plans may include:
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.
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.
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.
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:
First, find out what the client wants to achieve. Create goals that are relevant and meaningful to their life.
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.
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.
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.
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.
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.
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.
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.
Using SOAP notes software 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.