Occupational therapy SOAP Notes: Do’s and Don’ts

SOAP notes are a common format for documenting the progress of a patient in a clinical setting. They are an important tool for occupational therapists to use in order to track the patient’s progress, identify any problems or concerns, and plan for future treatment. Here are some tips for effectively using SOAP notes in occupational therapy:

Do:

• Use the SOAP format consistently: The SOAP format consists of four main sections: Subjective, Objective, Assessment, and Plan. Each section should be clearly labeled and include relevant information about the patient’s condition and progress.
• Be thorough and accurate: Make sure to include all relevant information about the patient’s condition, including any symptoms, functional limitations, and treatment goals. Be as specific as possible when documenting the patient’s progress, and make sure to accurately record any changes or improvements over time.
• Use SOAP notes to track progress and identify problems: SOAP notes can be a useful tool for tracking the patient’s progress over time, and for identifying any areas where the patient may be struggling or not making progress. Use the information in the SOAP notes to plan for future treatment and to adjust the patient’s treatment plan as needed.
• Collaborate with other members of the treatment team: SOAP notes can be a valuable tool for coordinating care among the different members of the treatment team. Make sure to share the SOAP notes with other members of the team, and to incorporate their feedback and observations into the notes.

Don’t:

• Use SOAP notes as a substitute for regular communication with the patient: SOAP notes are an important tool, but they should not be used as a substitute for regular communication with the patient. Make sure to talk to the patient about their progress and any concerns they may have, and to involve them in the decision-making process.
• Leave out important information: SOAP notes should be comprehensive and include all relevant information about the patient’s condition and progress. Don’t leave out any important details or observations, as this could lead to incomplete or inaccurate documentation.
• Use vague or unclear language: SOAP notes should be clear and concise, and should use language that is easily understood by other members of the treatment team. Avoid using jargon or technical language, and make sure to explain any terms or abbreviations that may not be familiar to others.
• Forget to update the SOAP notes regularly: SOAP notes should be updated regularly, at least every time the patient has a treatment session. This will help to ensure that the notes accurately reflect the patient’s progress and any changes in their condition.

How to Write SOAP notes: Step-by-Step with Examples

SOAP Note 1:

S: Patient reports increased difficulty with fine motor skills and hand strength in daily activities such as writing and holding utensils. O: Decreased hand strength and fine motor skills noted during observation of functional tasks. A: Develop a hand strengthening and fine motor skill training program to improve functional abilities. P: Begin with hand squeezes and progress to functional tasks such as writing and holding utensils. Monitor progress and adjust program as needed.

SOAP Note 2:

S: Patient reports difficulty with balance and mobility during activities of daily living such as showering and getting dressed. O: Impaired balance and mobility observed during functional tasks. A: Implement a balance and mobility training program, including use of assistive devices and exercises to improve stability and coordination. P: Begin with basic balance exercises and progress to functional tasks. Monitor progress and adjust program as needed.

SOAP Note 3:

S: Patient reports difficulty with memory and attention during daily activities such as completing tasks and remembering appointments. O: Impaired memory and attention noted during assessment. A: Implement a cognitive training program to improve memory and attention. P: Begin with memory games and exercises and progress to functional tasks. Monitor progress and adjust program as needed.