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SOAP Note Examples : Occupational Therapy

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What is a SOAP Note for Occupational Therapy? 

What does SOAP stand for in the occupational therapy documentation process? 

S = Subjective

O= Objective

A= Assessment

P = Plan

But, there is something you need to know. ‘SOAP’ for occupational therapy can be applied to every level of documentation!  As an occupational therapy practitioner, you complete MANY types of notes: Evaluations, Re-Certifications, Progress Notes, Daily Treatment Notes which include the objective parts of your treatments, and discharge notes! Holy smokes, right?!

SOAP NOTE format is designed to help you formulate your thoughts in a coherent and competent framework in micro and macro capacities so that you can be an advocate for the occupational therapy profession through defensive documentation. 


What is ‘defensive documentation’?  

SOAP Note styled occupational therapy documentation is a great format, maybe the best format if you are elevating your methods to defensive documentation.

You won’t be told this in school, but it is a ROUGH WORLD for an occupational therapy practitioner. They tell you the importance of advocating for your profession, but they don’t tell you WHY that is part of your curriculum!!! Well, I’ll tell you….it’s because nobody knows what occupational therapy can do and nobody knows our full scope of practice!!!!!

Defensive Documentation is something we have begun implementing over the past several years (Especially in outpatient physical medicine occupational therapy) because you must be ready to defend your approach to rehab . This means that you need to do the work to know your OTPF, know how to interpret it, and then master activity analysis. 

In defensive documentation, you are including activity analysis in the note itself along with information from research articles. This allows passive advocacy in the medical world when people read your reports as well as ensuring you are above reproach in your practical application.