Occupational Therapy: Step-by-Step Guide on How to Write SOAP Notes

SOAP notes are essential for effective patient care and documentation in occupational therapy. This guide provides detailed instructions for each section of a SOAP note, helping you understand the structure and content required for thorough documentation in the occupational therapy context. By mastering SOAP notes, you can enhance patient care, ensure effective communication among healthcare providers, and maintain accurate medical records.

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Subjective Section (S)

In an occupational therapy SOAP note, the Subjective section (S) captures the patient’s self-reported information about their condition and symptoms. This section provides context for the therapist to understand the patient’s perspective and experiences. Here are the specific things that should go into the Subjective section of an occupational therapy SOAP note:

Subjective Section (S) Components

1. Chief Complaint:

   • The primary reason the patient is seeking occupational therapy.
   • Example: "I have difficulty using my right hand after the stroke."

2. History of Present Illness/Injury:

   • Details about the onset, duration, and progression of the current condition.
   • Description of how and when the injury or condition occurred.
   • Example: "The difficulty started after a stroke three months ago."

3. Functional Limitations:

   • Impact of the condition on daily activities and functions.
   • Specific tasks or activities that are difficult or impossible due to the condition.
   • Example: "The patient has difficulty with dressing, eating, and writing."

4. Previous Treatments and Outcomes:

   • Information on any treatments the patient has previously received for the condition.
   • The effectiveness or outcome of those treatments.
   • Example: "The patient has been receiving physical therapy, which has improved mobility but not fine motor skills."

5. Relevant Medical History:

   • Any relevant past medical conditions, surgeries, or injuries.
   • Family history if applicable to the condition.
   • Example: "The patient has a history of hypertension and diabetes."

6. Medications:

   • Current medications the patient is taking, including dosage and frequency.
   • Any recent changes in medication.
   • Example: "The patient is taking aspirin and metformin."

7. Patient Goals:

   • The patient’s goals and expectations from occupational therapy.
   • Example: "The patient hopes to regain the ability to write and perform daily tasks independently."

8. Other Relevant Information:

   • Any other information provided by the patient that may be relevant to their treatment.
   • Example: "The patient reports frustration and anxiety due to the loss of independence."

Tips:

• Use the patient’s own words when possible.
• Be thorough in capturing all relevant information.
• Ask open-ended questions to gather detailed responses.

Example of a Subjective Section for Occupational Therapy

Objective Section (O)

In an occupational therapy SOAP note, the Objective section (O) captures measurable, observable, and factual data obtained during the patient’s examination. This section provides concrete evidence of the patient’s condition and progress. Here are the specific things that should go into the Objective section of an occupational therapy SOAP note:

Objective Section (O) Components

1. Vital Signs:

   • Record the patient’s vital signs such as blood pressure, heart rate, respiratory rate, and temperature if relevant to the session.
   • Example: "BP 130/85, HR 78, RR 18, Temp 98.4°F"

2. Physical Examination Findings:

   • Document the results of your physical examination, including inspection, palpation, and special tests.
   • Example: "Swelling and decreased range of motion in the right hand."

3. Range of Motion (ROM):

   • Measure and record the range of motion for relevant joints or body parts.
   • Example: "Right wrist flexion: 30 degrees (normal: 70 degrees), Right wrist extension: 20 degrees (normal: 70 degrees)"

4. Strength Tests:

   • Document muscle strength using a standardized scale (e.g., 0-5 scale).
   • Example: "Grip strength: 3/5 in the right hand."

5. Functional Assessments:

   • Record the results of any functional assessments performed, such as activities of daily living (ADL) assessments.
   • Example: "The patient requires moderate assistance for dressing and eating."

6. Cognitive and Perceptual Assessments:

   • Document any cognitive or perceptual assessments relevant to the patient’s condition.
   • Example: "The patient demonstrates difficulty with spatial awareness and problem-solving tasks."

7. Standardized Tests:

   • Include results of any standardized tests relevant to the occupational therapy session.
   • Example: "Nine-Hole Peg Test: 45 seconds (right hand), 20 seconds (left hand)."

Tips:

• Be precise and factual in your documentation.
• Include only measurable and observable data.
• Use standardized scales and measurements where applicable.

Example of an Objective Section for Occupational Therapy

Assessment Section (A)

In an occupational therapy SOAP note, the Assessment section (A) synthesizes the information gathered in the Subjective and Objective sections to provide a clinical judgment about the patient’s condition. This section includes the therapist's professional interpretation, diagnosis, and the patient’s progress and response to treatment. Here are the specific things that should go into the Assessment section of an occupational therapy SOAP note:

Assessment Section (A) Components

1. Diagnosis:

   • Provide a clinical diagnosis based on the subjective and objective findings.
   • Example: "Right hand hemiparesis secondary to stroke."

2. Clinical Impression:

   • Include your clinical interpretation of the patient’s condition.
   • Example: "The patient’s symptoms are consistent with right hand hemiparesis, impacting fine motor skills and daily activities."

3. Functional Limitations:

   • Document the impact of the patient’s condition on their daily activities and functional abilities.
   • Example: "The patient has significant limitations in dressing, eating, and writing due to decreased hand function."

4. Patient Progress:

   • Comment on the patient’s progress since the last visit, if applicable.
   • Example: "Since the last visit, the patient has shown slight improvement in grip strength but continues to struggle with fine motor tasks."

5. Prognosis:

   • Provide an outlook on the patient’s recovery based on their condition and response to treatment.
   • Example: "With continued occupational therapy, the patient has a fair prognosis for regaining functional use of the right hand within 6-12 months."

6. Goals:

   • Set specific, measurable, achievable, relevant, and time-bound (SMART) goals for the patient’s treatment.
   • Example: "Short-term goal: Improve grip strength to 4/5 within four weeks. Long-term goal: Achieve independence in dressing and eating within six months."

Tips:

• Be clear and concise in your clinical judgment.
• Use evidence-based reasoning to support your diagnosis and clinical impression.
• Set realistic and measurable goals for the patient.

Example of an Assessment Section for Occupational Therapy

Plan Section (P)

Plan Section (P) Components

1. Treatment Plan:

   • Specific interventions that will be implemented to address the patient’s condition.
   • Example: "Fine motor skill exercises to improve hand function."

2. Exercises:

   • Detailed description of the exercises prescribed, including the type, frequency, duration, and any progression plans.
   • Example: "Theraputty exercises for hand strengthening, 3 sets of 10 reps, twice daily."

3. Modalities:

   • Any therapeutic modalities that will be used, such as heat, ultrasound, or electrical stimulation.
   • Example: "Apply electrical stimulation to the right hand to improve muscle activation."

4. Patient Education:

   • Information and instructions provided to the patient to help them manage their condition and prevent further injury.
   • Example: "Educate the patient on adaptive techniques for dressing and eating."

5. Home Exercise Program (HEP):

   • Exercises and activities prescribed for the patient to perform at home between therapy sessions.
   • Example: "Home exercise program includes fine motor skill exercises using household items, to be performed twice daily."

6. Referral:

   • Any referrals to other healthcare professionals or specialists if necessary.
   • Example: "Refer the patient to a neurologist for further evaluation if no improvement is seen in three months."

7. Follow-Up:

   • The plan for subsequent visits, including the frequency and duration of follow-up appointments.
   • Example: "Schedule follow-up appointments twice a week for the next six weeks to monitor progress and adjust the treatment plan as necessary."

Tips:

• Be specific and detailed in your treatment plan to ensure clarity and adherence.
• Tailor the plan to the individual needs and goals of the patient.
• Ensure that the patient understands their role in the treatment plan, especially for home exercises and self-care.

Example of a Plan Section for Occupational Therapy

This detailed information in the Plan section ensures that the patient receives a comprehensive and personalized treatment strategy, and helps track progress and outcomes effectively.