How to Write Occupational Therapy Soap Notes

SOAP notes are an integral part of patient's therapy plan.
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Whereas physical therapy focuses on recovery from injury, occupational therapy aims to help patients cope with physical or mental disadvantages in a way that allows them to meaningfully participate in everyday activities. These may include activities necessary at home, school or work. As part of occupational therapy, you will write SOAP notes to document the progress of your patients. SOAP is an acronym for subjective, objective, assessment and plan.

Step 1

Interview your patient at the beginning of your therapy session and document her subjective state. This is the patient's opinion on her own status including activities with which she is having problems, progress she's made and her opinion of her physical and mental state. Document the patient's state as she reports it; avoid adding your judgment at this point. Do not include extraneous information such as gossip, personal stories or complaining that isn't related to the patient's ability to perform activities.

Step 2

Observe and measure the patient's objective state. This may include her mental status, communication, limb strength and range of motion. Note whether each of these points have improved or worsened since the patient's last session.

Step 3

Provide your assessment of the patient's status. This is your professional opinion of the improvement or worsening of the patient's ability to function. Document whether patient has been compliant with treatment program, whether the program is optimal and the factors contributing to progress or failure.

Step 4

Document your plan for continuing treatment of the patient. Include changes in the amount or variety of physical exercise. Outline your expectations and set specific milestones you'd like to see in continuing treatment.

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