10 Common Occupational Therapy SOAP Note Examples

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List of cases

1. Stroke Rehabilitation
2. Pediatric Developmental Delay
3. Hand Therapy Post-Surgery
4. Cognitive Rehabilitation
5. Activities of Daily Living Training
6. Sensory Processing Disorder
7. Geriatric Fall Prevention
8. Upper Extremity Rehabilitation
9. Work-Related Injury
10. Autism Spectrum Disorder

1. Stroke Rehabilitation

Description

The patient presents for occupational therapy following a right-sided CVA, focusing on improving independence in activities of daily living and upper extremity function.

SOAP Note

Patient Name: Thomas Anderson

Date of Visit: 09/01/2024

Subjective

Thomas Anderson, a 68-year-old male, presents 3 weeks post right MCA stroke. Reports difficulty with left upper extremity movement and daily activities. Lives with spouse in two-story home. Prior to stroke was independent in all ADLs/IADLs. Primary goals include returning to independent self-care and home management. Reports frustration with current limitations and motivation to improve.

Objective

• Vital Signs:
  • BP: 126/78 mmHg
  • HR: 76 bpm
  • RR: 16/min
• Upper Extremity Assessment:
  • Left UE Strength: 2/5 proximal, 1/5 distal
  • Modified Ashworth Scale: 1+ in left elbow flexors
  • Sensation: Diminished light touch on left
  • ROM: Limited by weakness on left
• Functional Assessment:
  • Barthel Index Score: 45/100
  • Dressing: Moderate assistance required
  • Feeding: Requires setup and supervision
  • Transfers: Minimal assistance with slide board
• Cognitive Status:
  • Alert and oriented x3
  • Following 3-step commands
  • Mild left neglect present

Assessment

1. Left Hemiparesis
   • Moderate upper extremity involvement
   • Impacts ADL performance
   • Good rehabilitation potential
2. Visual-Perceptual Deficits
   • Left neglect affecting safety
   • Impacts functional performance

Plan

1. Treatment Provided Today:

   • ADL training: Upper body dressing
   • Neuromuscular re-education
   • Visual scanning exercises
   • Duration: 45 minutes
   • CPT Codes: 97535, 97112

2. Focus Areas:

   • Upper extremity function
   • Self-care activities
   • Visual perception
   • Transfer training

3. Home Program:

   • Left UE ROM exercises
   • Visual scanning activities
   • One-handed techniques
   • Environmental modifications

4. Follow-up:

   • 3x weekly for 4 weeks
   • Monitor ADL independence
   • Track UE recovery

2. Pediatric Developmental Delay

Description

The patient presents for evaluation and treatment of global developmental delay affecting fine motor skills and daily activities.

SOAP Note

Patient Name: Emily Roberts

Date of Visit: 09/02/2024

Subjective

Emily Roberts, a 4-year-old female, presents with parent-reported concerns about fine motor skills and self-care abilities. Parents note difficulty with utensil use, drawing, and clothing management. Attending preschool with support. Previous physical therapy for gross motor delays. Parents report concerns about school readiness.

Objective

• Developmental Assessment:
  • Peabody Developmental Motor Scales-2:
    • Fine Motor Quotient: 72 (Below Average)
    • Grasping: Age equivalent 3.0 years
    • Visual-Motor Integration: Age equivalent 2.8 years
• Fine Motor Skills:
  • Immature pencil grasp (palmar supinate)
  • Difficulty with bilateral coordination
  • Limited in-hand manipulation skills
  • Decreased finger isolation
• Self-Care Skills:
  • Requires assistance with fasteners
  • Modified independence in eating
  • Dependent in shoe tying
  • Difficulty with tool use
• Sensory Processing:
  • Tactile defensiveness noted
  • Seeks vestibular input
  • Poor body awareness

Assessment

1. Developmental Coordination Disorder
   • Fine motor delay
   • Impacts ADL independence
   • Affects school participation
2. Sensory Processing Differences
   • Impacts engagement
   • Affects motor planning

Plan

1. Treatment Provided Today:

   • Fine motor activities
   • Sensory integration
   • ADL training
   • Duration: 45 minutes
   • CPT Codes: 97530, 97533

2. Focus Areas:

   • Grasp development
   • Bilateral coordination
   • Self-care skills
   • School readiness

3. Home Program:

   • Fine motor activities
   • Sensory strategies
   • ADL practice
   • Parent education

4. Follow-up:

   • 2x weekly for 12 weeks
   • Monitor developmental progress
   • Track functional gains

3. Hand Therapy Post-Surgery

Description

The patient presents for occupational therapy following surgical repair of right flexor tendon injury, focusing on rehabilitation and return to functional use.

SOAP Note

Patient Name: Michael Torres

Date of Visit: 09/03/2024

Subjective

Michael Torres, a 35-year-old male, presents 4 weeks post Zone II flexor tendon repair of right long finger. Reports compliance with home exercise program and splint wear. Pain rated 3/10 with movement. Works as computer programmer, currently on medical leave. Goals include return to typing and daily activities. No complications reported.

Objective

• Vital Signs:
  • BP: 122/76 mmHg
  • HR: 72 bpm
  • RR: 16/min
• Hand Assessment:
  • AROM long finger:
    • MCP: 0-45°
    • PIP: 0-30°
    • DIP: 0-20°
  • Edema: +1 in affected digit
  • Scar: Well-healed, slightly raised
  • Grip strength: Not tested due to protocol
• Functional Measures:
  • QuickDASH score: 68/100
  • Light touch sensation intact
  • Unable to make composite fist
  • Modified independence in ADLs

Assessment

1. Post-operative Flexor Tendon Repair
   • Progressing per protocol
   • Limited ROM
   • Functional limitations

Plan

1. Treatment Provided Today:

   • AROM exercises within protocol
   • Scar management
   • Edema control
   • Duration: 45 minutes
   • CPT Codes: 97110, 97140

2. Focus Areas:

   • Tendon gliding
   • Scar mobility
   • Edema reduction
   • ADL modifications

3. Home Program:

   • Protocol exercises
   • Scar massage
   • Splint wear schedule
   • Activity modifications

4. Follow-up:

   • 2x weekly for 4 weeks
   • Monitor ROM gains
   • Track protocol progression

4. Cognitive Rehabilitation

Description

The patient presents for cognitive rehabilitation following traumatic brain injury, focusing on improving executive function and daily task completion.

SOAP Note

Patient Name: Sarah Mitchell

Date of Visit: 09/04/2024

Subjective

Sarah Mitchell, a 42-year-old female, presents 2 months post moderate TBI from MVA. Reports difficulty with organization, memory, and multi-step tasks. Lives alone in apartment. Previously employed as accountant. Goals include return to independent living and work. Reports fatigue with cognitive tasks and headaches with prolonged concentration.

Objective

• Cognitive Assessment:
  • MoCA Score: 22/30
  • Trail Making Test:
    • Part A: 45 seconds (impaired)
    • Part B: 180 seconds (impaired)
  • Digit Span: Forward 5, Backward 3
• Functional Performance:
  • Requires cues for medication management
  • Difficulty with meal preparation
  • Calendar use initiated but inconsistent
  • Safety awareness intact
• Executive Function:
  • Problem-solving: Moderate impairment
  • Task initiation: Requires prompting
  • Mental flexibility: Decreased
  • Attention: Variable

Assessment

1. Cognitive-Communication Deficit
   • Executive function impairment
   • Memory limitations
   • Impacts daily function
2. Decreased Independence
   • IADL limitations
   • Work capacity affected

Plan

1. Treatment Provided Today:

   • Cognitive strategies training
   • IADL task practice
   • Compensatory techniques
   • Duration: 60 minutes
   • CPT Codes: 97129, 97130

2. Focus Areas:

   • Organization strategies
   • Memory techniques
   • Task sequencing
   • Time management

3. Home Program:

   • Calendar system use
   • Routine establishment
   • Environmental cues
   • Cognitive exercises

4. Follow-up:

   • 3x weekly for 6 weeks
   • Monitor cognitive gains
   • Track functional independence

5. Activities of Daily Living Training

Description

The patient presents for ADL training following total hip replacement, focusing on safe and independent completion of self-care tasks.

SOAP Note

Patient Name: Barbara Wilson

Date of Visit: 09/05/2024

Subjective

Barbara Wilson, a 72-year-old female, presents 1 week post left total hip replacement. Reports difficulty with dressing, bathing, and toilet transfers. Lives alone in single-story home with 3 steps at entry. Prior to surgery was independent with ADLs using rolling walker. Goals include return to independent living with adherence to hip precautions.

Objective

• Vital Signs:
  • BP: 128/82 mmHg
  • HR: 78 bpm
  • RR: 18/min
• Functional Status:
  • FIM Scores:
    • Lower body dressing: 3/7
    • Toileting: 4/7
    • Bathing: 3/7
    • Transfers: 4/7
• Physical Assessment:
  • Hip ROM within post-op limits
  • Standing balance: Fair with walker
  • Hip precautions maintained with cues
  • Decreased endurance with ADLs
• Home Safety:
  • Bathroom setup needs modification
  • Bed height appropriate
  • Adequate space for walker
  • Throw rugs present

Assessment

1. ADL Performance Deficit
   • Post-operative restrictions
   • Safety awareness good
   • Learning new techniques
2. Environmental Barriers
   • Home modifications needed
   • Fall risk factors present

Plan

1. Treatment Provided Today:

   • ADL training with equipment
   • Transfer training
   • Energy conservation
   • Duration: 45 minutes
   • CPT Codes: 97535, 97110

2. Focus Areas:

   • Dressing techniques
   • Bathing safety
   • Transfer methods
   • Hip precautions

3. Home Program:

   • Use of adaptive equipment
   • Energy conservation
   • Home safety modifications
   • Precaution adherence

4. Follow-up:

   • 3x weekly for 3 weeks
   • Monitor ADL independence
   • Track safety compliance

6. Sensory Processing Disorder

Description

The patient presents for evaluation and treatment of sensory processing disorder affecting participation in school and daily activities.

SOAP Note

Patient Name: Lucas Chen

Date of Visit: 09/06/2024

Subjective

Lucas Chen, a 6-year-old male, presents with parent and teacher concerns regarding sensory processing difficulties. Parents report challenges with clothing textures, food selectivity, and classroom participation. Demonstrates frequent movement seeking and difficulty with transitions. Currently in first grade with IEP support.

Objective

• Sensory Processing Assessment:
  • Sensory Profile-2 Results:
    • Seeking: Definite Difference
    • Avoiding: Probable Difference
    • Sensitivity: Definite Difference
    • Registration: Typical
• Behavioral Observations:
  • Constant movement during session
  • Avoids certain textures
  • Covers ears with loud sounds
  • Poor attention to tasks
• Motor Skills:
  • Age-appropriate gross motor
  • Decreased fine motor precision
  • Postural insecurity noted
  • Motor planning challenges
• Participation:
  • Limited peer interaction
  • Difficulty in group activities
  • Anxious in new situations
  • Resistant to routine changes

Assessment

1. Sensory Processing Disorder
   • Mixed pattern presentation
   • Impacts school participation
   • Affects daily routines
2. Motor Planning Difficulties
   • Impacts activity engagement
   • Affects social participation

Plan

1. Treatment Provided Today:

   • Sensory integration activities
   • Motor planning tasks
   • Environmental modifications
   • Duration: 45 minutes
   • CPT Codes: 97533, 97530

2. Focus Areas:

   • Sensory regulation
   • Motor planning
   • Social participation
   • Routine management

3. Home Program:

   • Sensory diet activities
   • Environmental adaptations
   • Visual schedules
   • Parent strategies

4. Follow-up:

   • 2x weekly for 12 weeks
   • Monitor sensory regulation
   • Track participation levels

7. Geriatric Fall Prevention

Description

The patient presents for evaluation and treatment following recent falls, focusing on home safety and fall prevention strategies.

SOAP Note

Patient Name: Margaret Johnson

Date of Visit: 09/07/2024

Subjective

Margaret Johnson, an 84-year-old female, presents with history of 3 falls in past 6 months. Reports increasing fear of falling affecting daily activities. Lives alone in senior apartment. Uses walker for community mobility. Reports difficulty with bathroom tasks and kitchen activities. Goals include maintaining independence and preventing future falls.

Objective

• Vital Signs:
  • BP: 132/78 mmHg
  • HR: 76 bpm
  • RR: 18/min
• Balance Assessment:
  • Berg Balance Scale: 32/56 (High Fall Risk)
  • TUG Test: 18.5 seconds
  • Functional Reach: 6 inches
  • Single leg stance: Unable
• Home Safety Assessment:
  • Poor lighting in bathroom
  • No grab bars installed
  • Cluttered walkways
  • High cabinet reach required
• Functional Mobility:
  • Transfers: Modified independent
  • Ambulation: Walker-dependent
  • Stairs: Unable
  • ADLs: Modified independent

Assessment

1. Fall Risk
   • Multiple risk factors
   • Environmental hazards
   • Fear affecting function
2. Activity Limitation
   • Safety concerns
   • Environmental barriers

Plan

1. Treatment Provided Today:

   • Balance activities
   • Transfer training
   • Home safety education
   • Duration: 45 minutes
   • CPT Codes: 97110, 97535

2. Focus Areas:

   • Balance strategies
   • Safe transfers
   • Environmental modifications
   • Activity adaptation

3. Home Program:

   • Home exercise program
   • Safety checklist
   • Fall prevention strategies
   • Emergency planning

4. Follow-up:

   • 2x weekly for 6 weeks
   • Monitor fall risk
   • Track safety implementation

8. Upper Extremity Rehabilitation

Description

The patient presents for rehabilitation following rotator cuff repair, focusing on return to functional use of right upper extremity.

SOAP Note

Patient Name: Robert Davis

Date of Visit: 09/08/2024

Subjective

Robert Davis, a 58-year-old male, presents 8 weeks post right rotator cuff repair. Reports progress with ROM but continued difficulty with overhead activities and lifting. Works as electrician, currently on modified duty. Pain rated 3/10 with activity. Goals include return to full work duties and independent home maintenance tasks.

Objective

• Vital Signs:
  • BP: 124/76 mmHg
  • HR: 72 bpm
  • RR: 16/min
• ROM Assessment (Right):
  • Flexion: 140°
  • Abduction: 120°
  • External Rotation: 45°
  • Internal Rotation: To L1
• Strength Testing:
  • Flexion: 4-/5
  • Abduction: 3+/5
  • External Rotation: 3+/5
  • Internal Rotation: 4/5
• Functional Testing:
  • Unable to reach overhead
  • Difficulty with resistance
  • Modified work techniques
  • Compensatory patterns noted

Assessment

1. Post-operative Status
   • Progressing per protocol
   • ROM limitations
   • Strength deficits
2. Functional Limitations
   • Work restrictions
   • ADL modifications needed

Plan

1. Treatment Provided Today:

   • Therapeutic exercise
   • Manual therapy
   • Work simulation
   • Duration: 45 minutes
   • CPT Codes: 97110, 97140

2. Focus Areas:

   • ROM progression
   • Strength training
   • Scapular stability
   • Work conditioning

3. Home Program:

   • HEP progression
   • Activity modifications
   • Posture awareness
   • Work techniques

4. Follow-up:

   • 2x weekly for 4 weeks
   • Monitor ROM/strength gains
   • Track work readiness

9. Work-Related Injury

Description

The patient presents for evaluation and treatment of work-related carpal tunnel syndrome, focusing on symptom management and ergonomic intervention.

SOAP Note

Patient Name: Lisa Martinez

Date of Visit: 09/09/2024

Subjective

Lisa Martinez, a 45-year-old female, presents with bilateral hand numbness and pain, right worse than left. Works as data entry specialist, 8+ hours daily at computer. Reports night symptoms disrupting sleep, rated 7/10. Symptoms worse with prolonged typing. Conservative treatment with splints and NSAIDs providing minimal relief. Goals include maintaining work performance and managing symptoms.

Objective

• Vital Signs:
  • BP: 118/74 mmHg
  • HR: 70 bpm
  • RR: 16/min
• Upper Extremity Assessment:
  • Positive Tinel's sign bilaterally
  • Positive Phalen's test at 30 seconds
  • Decreased grip strength R>L
  • Normal ROM all joints
• Workstation Evaluation:
  • Non-adjustable desk height
  • Monitor height too low
  • Non-ergonomic keyboard
  • Poor wrist positioning
• Functional Testing:
  • Typing speed decreased 30%
  • Frequent rest breaks needed
  • Modified grip patterns
  • Difficulty with fine manipulation

Assessment

1. Bilateral Carpal Tunnel Syndrome
   • Work-related factors
   • Ergonomic issues
   • Activity limitations
2. Workstation Setup
   • Multiple deficits
   • Contributing to symptoms

Plan

1. Treatment Provided Today:

   • Ergonomic education
   • Neural gliding exercises
   • Work simulation
   • Duration: 45 minutes
   • CPT Codes: 97535, 97110

2. Focus Areas:

   • Workstation modification
   • Body mechanics
   • Symptom management
   • Work techniques

3. Home Program:

   • Nerve gliding exercises
   • Ergonomic principles
   • Activity modification
   • Splint wear schedule

4. Follow-up:

   • 2x weekly for 6 weeks
   • Monitor symptom levels
   • Track work tolerance

10. Autism Spectrum Disorder

Description

The patient presents for occupational therapy to address daily living skills and social participation affected by autism spectrum disorder.

SOAP Note

Patient Name: James Thompson

Date of Visit: 09/10/2024

Subjective

James Thompson, an 8-year-old male with ASD, presents with parent concerns regarding self-care independence and social participation. Parents report difficulty with morning routine, hygiene tasks, and peer interactions at school. Currently in mainstream classroom with aide support. Previous OT focused on sensory integration. Goals include increased independence in daily routines and improved social engagement.

Objective

• Functional Skills Assessment:
  • PEDI-CAT Scores:
    • Daily Activities: 45
    • Social/Cognitive: 38
    • Responsibility: 42
    • Mobility: 52
• Social Skills:
  • Limited eye contact
  • Parallel play predominant
  • Difficulty with turn-taking
  • Prefers solitary activities
• Self-Care Skills:
  • Requires verbal cues for sequencing
  • Independent in feeding
  • Needs assistance with grooming
  • Difficulty with fasteners
• Sensory Processing:
  • Auditory sensitivity
  • Seeks proprioceptive input
  • Mixed tactile responses
  • Visual preference for learning

Assessment

1. Autism Spectrum Disorder
   • Social skill deficits
   • Self-care limitations
   • Sensory processing differences
2. Routine Management
   • Sequencing difficulties
   • Transition challenges
   • Requires structure

Plan

1. Treatment Provided Today:

   • Social skills activities
   • ADL training
   • Sensory strategies
   • Duration: 45 minutes
   • CPT Codes: 97533, 97530

2. Focus Areas:

   • Morning routine
   • Peer interaction
   • Self-care skills
   • Sensory regulation

3. Home Program:

   • Visual schedules
   • Social stories
   • Sensory strategies
   • Parent coaching

4. Follow-up:

   • 2x weekly for 12 weeks
   • Monitor skill acquisition
   • Track social participation