SOAP Notes For Occupational Therapy Template

What should be included in an occupational therapy SOAP note?

The SOAP note format is well-known worldwide and used in many healthcare settings. SOAP stands for Subjective, Objective, Assessment, and Plan. Healthcare professionals across different specialties use this format to help organize information systematically. Likewise, occupational therapists can follow this structure to ensure a comprehensive and clear documentation process.

An occupational therapy (OT) SOAP notes template is designed to help take comprehensive and well-structured notes during client sessions. The following are included when writing SOAP notes for your occupational therapy practice:

Subjective

This is where you will write down information specific to what the client or patient reports, including their feelings, pain level, mood, and any new or progressing symptoms. Their priorities and goals for the session may also be relevant to this section and will help guide your session. Suppose this is your first session with your patient. In that case, you may record a more comprehensive history of your client, including why they are seeking occupational therapy services, present symptoms, medications, allergies, and past treatments.

Objective

The objective section is for measurable or observable facts. Your client's response to a given task, their ability to complete a task with or without assistance, the results of a physical exam, or details you observe of their functioning may all be relevant here.

Assessment

In the assessment section, you can write your professional opinion as an occupational therapist of the patient's current ability or performance in relevant tasks. This summary will be based on the subjective and objective information you gathered in the first two sections.

Plan

What are the next steps for your client? Include specific details like any resources you provided, any exercises or tasks you left them to practice between sessions, treatment notes, or anything you will focus on in your client's following sessions.

How to use our OT SOAP note template 

Our occupational therapy SOAP note template is designed to help practitioners create structured and accurate documentation, especially after a therapy session. Here's a step-by-step guide on how to use this resource as you write a SOAP note:

Step 1: Access and customize the template

You can access the SOAP note template through this guide. Click "Use template" to open and edit it within the Carepatron platform or "Download" to access a fillable PDF copy. You can also refer to our SOAP note example, which guides you on how to complete this template.

Step 2: Fill in the information

At the top of the template, input essential patient information such as name, date of birth, and gender. Include the date of the session, your name as the treating therapist at the bottom, and any other relevant details such as their history or diagnoses, if any. This ensures easy identification and organization of notes.

Step 3: Complete each section

Work through each section of the SOAP note, filling in relevant information for the subjective and objective data, assessment, and plan sections. Use clear, concise language and include specific, measurable data where possible.

Step 4: Review and refine

Before finalizing your note-taking process, review it for completeness, accuracy, and clarity. Ensure you've included all necessary information and that your documentation aligns with your clinical reasoning and treatment goals. Make any necessary edits or additions to provide a comprehensive picture of the session and patient progress.

Step 5: Save and share if needed

Once you're satisfied with the note, sign and save it securely in the patient's electronic health record or file it appropriately using paper documentation. Share the information with relevant team members as needed, always adhering to privacy and confidentiality guidelines.

Benefits of using the SOAP Notes For Occupational Therapy Template

This template offers several benefits for practitioners who intend to write SOAP notes or improve how they do their documentation regarding occupational therapy sessions. Here are the key benefits of incorporating this template into clinical practice:

Standardization and consistency

Using a standardized template ensures that all essential elements of patient care are consistently documented. This uniformity makes it easier for other healthcare providers to quickly locate and understand important information, improving communication and continuity of care.

Time efficiency

A well-designed template streamlines the documentation process, allowing therapists to complete notes more quickly and efficiently. By providing a clear structure, the template reduces the time spent organizing thoughts and deciding what information to include.

Improved clinical reasoning

The SOAP format encourages a logical progression of thought, from gathering information (Subjective and Objective) to analysis (Assessment) and treatment plan or action (Plan). This structure supports clinical reasoning by prompting therapists to systematically consider all aspects of patient care. It helps identify patterns, track progress, and make informed decisions about treatment adjustments.

Enhanced goal tracking

The template facilitates consistent documentation of progress toward treatment goals. Therapists can easily track and update short-term and long-term goals by having a dedicated space for assessment and planning. This ongoing evaluation ensures that treatment remains focused and effective, promoting better patient outcomes.

Legal and ethical compliance

Comprehensive and accurate documentation is crucial for legal and ethical reasons. The SOAP note template helps ensure that all necessary elements are included in each note, reducing the risk of omitting important information. This thoroughness can be invaluable in case of audits, legal inquiries, or insurance reviews.