SOAP Notes for Occupational Therapy Evaluations are used for the both the format of most plans of care AND used to construct your occupational therapy goals (short term and long term). Here’s a secret, many plans don’t require short term goals and only require long term goals. To be safe, there has never been a time where I leave out short term goals as these goals are used as ‘milestones’ toward the ultimate graduating/mid-way goal. So let’s break it down.
S = Subjective
O = Objective
A = Assessment
P = Plan
What is going on with the client? What did they say? What are they feeling? Upcoming appointments? Did the caregiver mention anything? How do they present? Always comment on the presentation, but never add your own interpretation!
Specific exercises/activities/interventions. Be specific! Tell what the exercise is working on using activity analysis and why you should be the one doing it vs. an activity leader. Why is it skilled and what is the clinical rationale for the treatment? How any repetitions and sets? How did the patient respond? If you educated the client, how do you know the patient understood what was explained? Finally how did the patient do with the activity and how did the patient present post-activity. Was the activity terminated due to shortness of breath (SOB) or early-onset of fatigue? What did you do about that?
Remember that this section does not have feelings or interpretation!! This is the data. This is rigid, black and white information.
Summarize Subjective and Objective sections of your daily treatment note and interpret the results using clinical reasoning and rationale. What should the doctor know about the treatment? What should another OT know about your patient and plan of care continuum if they need to take over your patient or caseload? How can you explain your treatment in a snapshot? Finally, why should this person continue to have skilled services through Occupational Therapy? If they shouldn’t, why not?
Be specific with your rationale and reasoning for continued services based on DAILY support!
If you will be continuing the POC, what will you work on in the next daily treatment?