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Occupational Therapy SOAP Notes

SOAP Notes :

Occupational therapy SOAP notes for those of you who are not familiar with this terminology, a SOAP note is a way of documenting what you do during a therapy treatment session. It is a way to write a daily note. Some facilities have their own facility created format that you must use. In some settings, you basically write what we call a narrative—which is essentially a paragraph, but it usually contains all the SOAP information– so sometimes it feels more organized to go ahead and instead of writing a narrative, write a SOAP note if your setting allows.

Most students are required to learn and must practice how to write these. Although I have never used this format in the pediatric setting, I have used it in just about every adult setting I have worked. I feel that being able to write a SOAP note is important even if you don’t use it where you work because it helps you organize your thoughts. This is particularly important for students to be able to do this.

Most students have a difficult time writing these. Mine are by no means perfect and they will vary from one setting to the next, but we are often asked for examples of daily notes, which is why I am creating this document.

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SOAP stands for:

S-Subjective information (usually something the client says that is relevant in some way)

O-Objective information (what they did)

A-Assessment information (how they did)

P-Plan (what are you doing to do next?)

S: Child stated, “My momma had a baby.” Or if child is non-verbal…Child rode tricycle to therapy room smiling…or Child crying and was in time-out when OT arrived to classroom

O: Child (decide if you are going to call them child or client and stick with one or the other) seen for yyy minute OT session in therapy gym focused on fine and visual motor activities. Prior to seated activities, child participated in an obstacle course consisting of jumping, climbing and crawling to retrieve various objects. Child required Max verbal cues with completing obstacle course in sequence. Child sat at child size table and performed a 12 pc jigsaw puzzle with Max A to orient and place pieces. He completed visual motor worksheets of mazes, tracing and coloring inside the lines with multiple deviations noted. Child utilized an immature, digital pronate grasping pattern and required Max verbal and tactile cues to maintain a proper grasping pattern on writing instruments. He required Max cues to remain seated and complete therapist directed tasks. Child required no verbal cues this session to use his “inside voice.”

A: Decreased motor planning/sequencing AEB (as evidenced by) Max A with obstacle course; Decreased visual perceptual skills AEB by Max A to complete jig saw puzzle; Decreased visual motor skills AEB multiple errors with worksheets and inability to remain inside the boundaries of mazes or when tracing; Decreased attention to therapist directed activities AEB Max verbal cues required to complete table activities. Decreased grasp AEB Max cues to correct and maintain proper grasping pattern. Improvement noted with regulating voice by not talking too loudly this session.

P: Continue with OT POC (plan of care) for yyy MPW (minutes per week) to focus on increasing fine and visual motor skills to an age appropriate level as needed for improved classroom performance/improved performance with pre-academic work/improved play skills.

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At an LTACH …

S: Client mouthing words due to vent. Client mouthed, “I feel good today.”

O: Client received alert and oriented x 4 (person, place, time and situation) reclined in bed on ventilator via trach. O2 sats 95% on CPAP wean. HR 89 bpm. Client seen for yyy minute therapy session in room focusing on light ADLs, mobility skills and UE there ex. Client moved to EOB with Max A. Client performed light grooming and hygiene tasks seated at EOB set-up A. CGA required to maintain static sitting balance at EOB. Client transferred from EOB to w/c with Max A for SPT (stand pivot transfer). Once seated in chair, client instructed in and performed 3 x 10 UE ther ex with Mod resistance theraband. O2 sats dropped to 90% during ex’s on 2 occasions, but quickly returned to 95% after 30 sec rest break. Client requested multiple rest breaks during exercise. Client left seated in w/c, brakes locked with call light.

A: Decreased mobility skills (bed and with transfers) AEB Max A with transfers; Decreased activity tolerance AEB multiple rest breaks with exercise; Decreased functional mobility skills needed for advanced ADLs AEB Max A to stand and with transfers.

P: Cont with OT POC yyy MPW for yyy weeks to increase strength, endurance and functional mobility skills as needed for vent weaning and to improve performance and participation in Advanced ADLs.

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http://gkseek.com/occupational-therapist-assistant-salary-2019-in-the-united-states/

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