SOAP Note for Occupational Therapy
{Progress Notes}
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SOAP Notes for Occupational Therapy progress notes are a time where you analyze all of your assessments/patient education and capture the main trend. Based on performance over time, where are you now and where are you headed? The occupational therapist and the occupational therapy assistant can performing progress note assessments. Depending on the setting you are in and the electronic medical records system they are using for documentation, the format of your SOAP progress note may be different—but the general execution should remain the same.
General Guidelines
S = Subjective
O = Objective
A = Assessment
P = Plan
S
As is the case for all “subjective” information, never add your own interpretation! In the subjective section of a progress note, update any patient perceptions or major events that have influenced the plan of care to date. New diagnosis? Role change? Increased reported anxieties? Increased reported confidence. All of these are important to update in a progress note. Again, this is information that the patient has reported in their subjective sections throughout the progress period.
O
Update your objective measures. This section of the progress note contains all of your baseline measurements. The following assessments are examples of what assessments you can update in your progress note: MMT, ROM, BERG, DASH, TUG, 9 hole peg, SLUMS, ABC Balance Confidence Scale, etc.
As you update these objective measures, consider what it means. How are you going to interpret these outcomes? Has your patient improved, declined, or remained the same? Are you going to discharge this goal or keep working towards it? Why or why not? All of this information must be interpreted in the next section of the progress SOAP Note.
Remember that this section does not have feelings or interpretation!! This is the data. This is rigid, black and white information.
A
Summarize Subjective and Objective sections of your progress note and interpret the results using clinical reasoning and rationale.
- What should the doctor know about the patient’s progress to date?
- What should another OT know about your patient and plan of care continuum if they need to take over your patient or caseload?
- What gains have they made? Summarize your objective measures.
- Have new barriers presented themselves which impact therapeutic potential?
- Why should the patient continue occupational therapy services?
- Why should they begin the disengagement process?
P
In a progress note, the plan represents your goals which includes major goal and milestones or checkpoints. Always provide a specific update on each goal. If short term goals/checkpoints have been completed, update and discharge them. If you are still working towards a goal but it remains relevant, be sure to state that. Always update the providers on your progress.
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