Writing SOAP
NOTES
What are SOAP notes?
SOAP notes stands for: Subjective, Objective, Assessment and Planning.
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• S >> Subjective (What is SAID)
Write in this section anything that someone says to you or reports. This can be the patient, a
relative, or a member of the MDT. This can be face to face or on the phone. The type of stuff
that goes in this section includes:
Consent to treatment
Social history from patient or family member
how the patient says they are feeling
client goals and wishes on discharge
You can start by writing :
• Client reports ....
• Client states “......”
EXAMPLE:
• Client reports that she was admitted after a fall that resulted in confusion and left sided
weakness. Prior to admission she was living alone in a one story home and was independent in
all ADLs. She reports that she is a retired librarian, widowed 10 years ago. She says she values
her independence and fully intends to return to her own home. She says her daughter lives
two blocks away and provides transportation when needed.
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• O >> Objective (What you have OBSERVED)
This is anything that you’ve seen. You will record all measurable, quantifiable, and observable
data obtain during the treatment session. In the objective section write your observations,
results of standardized and non-standardized assessments, range of movement, initiation of task,
distance of mobilization, assistance levels and equipment required.
• Three steps to writing good OBSERVATIONS:
begin with a statement about the setting and purpose of the treatment session
follow the opening statement with a summary of what you observed
be professional, concise, and specific
• Helpful templates to write Observations:
EXAMPLE:
• Client participated in 30 minutes of right UE strengthening in therapy gym in order to prevent
future shoulder dislocation. Client was asked to clasps hands together and raise arms above
head 30 times. Client was then instructed to cross her midline and touch her opposite shoulder
with right UE. Client required 6 rest periods for completion. Client completed task
independently. After strengthening exercise, client had 3 heat packs applied to shoulder to
decrease pain.
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• A >> Analysis (your ASSESSMENT)
This is the section that demonstrates your clinical reasoning as an occupational therapist.
Summarize your clinical reasoning by writing the conclusions that you have reached from the
subjective and objective and how they are affecting the clients occupational function. In the
Assessment section remember the 3 Ps: PROBLEMS, PROGRESS, and POTENTIALS.
EXAMPLE:
• Decreased postural control and need for facilitation of weight shift limits infant’s ability to
perform early mobility skills needed for play (PROBLEM). Limited mobility combined with her
tolerance for less than 20 minutes of activity and the need for frequent rest breaks limit her
ability to explore her environment and reach developmental milestones at a typical age
(PROBLEM). Ability to perform transitional movements with facilitation, orientation to black and
white design, and ability to track in horizontal plane show good potential for future
developmental gains (PROGRESS & POTENTIAL). Infant would benefit from continued OT
services to stimulate developmental skills and from parent education in a home program.
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• P >> Plan
As a result of your analysis, what needs to be done? End with a statement justifying the
continued need for OT input if required. You document the anticipated frequency and duration of
your services and the specific interventions that will be used to achieve the client’s goals (LTG &
STG). In the Plan write any updated goals, modifications to therapy and subsequent treatment
sessions.
EXAMPLE:
• Continue to treat the client 3 times a week for 2 weeks to increase tolerance of sensory
media and to decrease oral defensiveness. Focus will be on increasing tolerated food textures
and improving oral range needed for self feeding. Mother will be instructed in home activities
to enhance the child’s development of sensory processing skills.
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