SOAP Notes Cheat Sheet for Occupational Therapy Documentation

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1 SOAP Notes for Occupational Therapy
2 Why do we do it?
3 Differences
4 S – Subjective
5 O – Objective
6 A – Assessment
7 P – Plan

SOAP Notes for Occupational Therapy

S-O-A-P = Subjective Objective Assessment Plan

Documentation takes practice. When writing SOAP notes (which is one way of documentation – there are others), the main tip is to be concise.

Why do we do it?

“If you didn’t document it, then it didn’t happen!”

Documentation such as with SOAP notes allows clients and patients to be billed by insurance (if applicable) for reimbursement. It may be required by your employer or other entities. It also protects your license (to CYA). Be ethical, don’t make up stuff or fudge details.

Last, it is a form of communication between healthcare professionals. You know how in your family, you may share a bar of soap? SOAP notes are shared. Write with the assumption that another therapist (e.g., speech-language pathologist, physical therapist), healthcare provider (e.g., case manager), or any other third party (e.g., a subpoena in court) will read your note. In other words, another therapist should be able to read your note, understand what you and your client did (and be able to replicate and re-do the same session in theory), and be able to move forward and continue towards the client’s goals and discharge.

Differences

Another challenge (at least academically) is differentiating between the specific components of the SOAP notes. Students and new practitioners may confuse a subjective for an objective, or more commonly, an objective for an assessment.

Subjective is something that a client stated in their own words, like a quote in a book. Subjective is personal.

Objective is something that you, the occupational therapist either observe, measure, or gather in terms of data (think researcher, like a scientist in a phenomenological psychology study). Examples of objective include ROM measurements, strength scores from MMT, flat affect, hyperverbosity, vital signs, decubitus ulcers, and transfers.

Assessment builds on subjective and objective and is a clinical interpretation. Another way to think of assessment is informed opinions, theories, explanation, and your interpretations or impressions. In my opinion, this is the part that makes occupational therapy practitioners skilled professionals. In addition to gathering the subjective and objective data (which may be considered someone with less training may be able to do), the assessment part is where you apply our OT thinking hat.

Last is plan, which is very intuitive – this is often the easiest one for students to understand. Just remember to include the necessary components for a good plan SOAP note.

S – Subjective

  • May come from/part of the (1) past medical history and (2) occupational profile.
  • Include subjective information about the client’s past to help define the problem.
    “I lived by myself and was completely independent.”
  • Include pertinent client’s quotes (broad). e.g.,  “I want to be more independent.”
  • Include the client’s complaints. e.g., “I can’t, I’m in too much pain!”
  • Include client’s goals. e.g., “I want to take care of my plants.”
  • Include client’s own perspective of their progress. e.g., “I think I have gone backwards.”
  • Reported pain scores, e.g., 6/10 pain, would go here as it is a client’s subjective thing (pain is often considered to be subjective). However, you may include relevant pain signs as observations, but in the O section, e.g., client self-braced their abdomen as they sneezed.1 
  • May be a direct quotation or a paraphrase (client reported that…).
  • Contextually, this means to include concerns, limitations, or personal problems.
  • Do not include answers or measurements from screens or assessments.

O – Objective

“Symptoms are the patient’s subjective description and should be documented under the subjective heading, while a sign is an objective finding related to the associated symptom reported by the patient.”2 

  • May come from screenings, evaluations, assessments, observations, or activity analysis – either from you or other staff or instruments.
  • Include facts and data.
  • Examples include ROM, strength, WNL, trace, skin and wound state, transfers, facial expressions, and speech.
  • May be organized chronologically (most intuitive), categorically, based on the assessment format (e.g., COPM), or whatever would make the most sense for the note.
  • A helpful guide that provides ideas of what to include in terms is the Occupational Therapy Practice Framework (OTPF) table on performance skills.
    • “Performance skills are observable, goal-directed actions that result in a client’s quality of performing desired occupations. Skills are supported by the context in which the performance occurs, including environmental and client factors (Fisher & Marterella, 2019).”3 
    • In the OTPF-4 are terms and definitions of specific skills followed by examples and ineffective examples. For example: How does one position their body? Obtain and use objects? Move about their environment? Sustain their performance? Apply their learning? Organize their timing? Interact socially?
    • Be careful not to go into the realm of assessment though!
  • Conditions such as skin conditions, vital signs, joint nodules, and residual limbs.
  • Document function and dysfunction.
  • Include deficits and also strengths.
  • Be sure the objective information is relevant to the client’s problem. You could document objective information all day and include unnecessary details, e.g., client’s height is really irrelevant. However, if a client with an eating disorder wants to manage their weight, then that would be pertinent to include.
  • Do not include your opinions, insight, interpretations, draw connections or anything like that (belongs in assessment). Two therapists should be able to document the same objective with relative similarity.

A – Assessment

  • Include your interpretation or impression of the subjective and objective.
  • Analyze the subjective and objective.
  • Include the client’s response to treatment such as their attitude or cooperation.
  • Document condition changes and progress such as improvement or decreases.
  • Be careful of using terms such as “plateau” as this may suggest an expectation to discharge the client.
  • Include the client’s rehab potential.
  • Recommend a summary of the client’s needs, e.g., equipment needs.
  • Suggest discharge plans and referrals.
  • Do not include any new information.

P – Plan

  • Plan should connect back to the assessment section.
  • Include short-term and long-term goals (evaluation, re-assessment).
  • Include any precautions to be taken with the client.
  • Include treatments and activities focused on a resolution to the problem.
  • Include any necessary client/family education and training.
  • Include final discharge plans.
  • Include equipment plans.
  • Include resource recommendations.
  • Include evaluations and re-evaluations.
  • Include any consultations with the medical team.

 

  1. Xu X, Huang Y. Objective Pain Assessment: a Key for the Management of Chronic Pain. F1000Res. 2020 Jan 23;9:F1000 Faculty Rev-35. doi: 10.12688/f1000research.20441.1. PMID: 32047606; PMCID: PMC6979466.[↩]
  2. Podder V, Lew V, Ghassemzadeh S. SOAP Notes. [Updated 2022 Aug 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482263/
    [↩]
  3. Fisher, A. G., & Marterella, A. (2019). Powerful practice: A model for authentic occupational therapy. Fort Collins, CO: Center for Innovative OT Solutions.[↩]