Documentation &

SOAP NOTES

Rahaf Abu Roza

 SOAP NOTES
The WHO (We document for):
➢ Intervention team
➢ Client and/or caregivers, family members
➢ Third party payers
➢ Accreditation agencies
The WHAT of documentation (Your documentation should tell the story – the progression
of Treatment):
➢ What you did with the person
➢ Client response to intervention
➢ Plan for future Treatment

If it’s NOT documented…it didn’t happen.

The WHEN of documentation
➢ Daily notes- done after each Treatment, usually quick and short
➢ Progress notes- done at a particular Treatment interval (ex. After 6 sessions),
describes the progress made by the person
➢ Evaluation- Completed the first time you work with someone, serves as a baseline for
everything you do in the future, time intensive
➢ Re-evaluation- done after a change in medical status/circumstances
➢ Discharge- Last note written for a person, summarizes everything done from eval to
discharge and all the progress/regressions made by the person.
The WHERE of documentation (Standards for documentation are the same despite the
setting in which you practice)
➢ Clinical settings
➢ Inpatient vs. Outpatient
➢ Educational settings
The WHY of documentation
➢ Chronological sequence of treatment
➢ Clinical reasoning
➢ Communication record for others
➢ Third party payers
➢ Legal reasons
Occupational therapy documentation should always contain the following:

♦ What services were provided and when they were provided.

♦ What was said and what happened.

♦ How the client responded to the service provided.

♦ Why the skill of an occupational therapy practitioner was required rather than the services
of an aide, a family member, or another professional. Before you write anything in the
record, make these assumptions:

♦ Someone else will have to read and understand what I write because I may be sick or out
of town the next time this client needs to be treated.

♦ This entry I am about to make will be scrutinized by a third-party payer. If I were a

Medicare reviewer, would I want to pay for the services I am about to record?

♦ My client will exercise his or her right to read this record.

There are several rules that should always be followed when documenting in the health
record:

• Always use waterproof, nonerasable black ink-. This prevents smearing, erasing, or
otherwise changing the health record.
• Correct errors: Never use correction fluid or correction tape! It is considered an
illegal alteration of the record. If you make an error in the health record, draw a
single line through it, write your correction, and initial the change: CG Pt. able to
dress lower body with verbal cues min (A) using a Reacher.
• Be as concise as possible without leaving out pertinent data-. You will have limited
time for documentation under today’s productivity standards, and other busy
professionals appreciate being able to read what you have written in the shortest
time possible.
• Sign and date every entry-. Some facilities and funding sources also require you to
document the time of day or number of minutes that the client received services.
The standard format is first name, middle initial, last name, and credentials. Notes by
students must be co-signed by a supervising therapist, and in some settings, notes by
occupational therapy assistants must be co-signed by the supervising occupational
therapist.
• Document in a timely manner-. It is best to document as soon after a session as
possible. This allows for the best communication between team members. It also
ensures that your recollection of events will be accurate
• Use appropriate terminology for the recipient of services-. When referring to the
persons who receive occupational therapy services, the terms client, patient,
consumer, resident, veteran, participant, individual student, teacher, child, caregiver,
employer, or family may be used. Use the term that is considered most respectful for
your practice setting.
• Be prudent in using abbreviations-. Use only the abbreviations that are approved by
your facility
• Focus on the client’s experience and leave yourself out-. Unless it is absolutely
relevant, do not mention yourself in the note. It is not necessary to say, “Therapist
provided caregiver with skilled instruction in assisting client with self-care.” Simply
say, “Caregiver received skilled instruction in assisting client with self-care.” In the
rare cases when it is necessary to mention yourself in the note, refer to yourself in
the third person. Do not use “I” or “me.” Instead use “the therapist,” “the clinician,”
or “the OT.” For example: “Client cursed and pushed therapist’s hand away when
physical assistance was provided for grooming task.”
• Always be accurate and objective-. Report what was actually observed and avoid
judging or interpreting the observations other than in the assessment portion of your
note.
• Avoid spelling, grammar, and punctuation errors-. As previously stated, your
documentation is a reflection of your skills and professionalism. Errors in
documentation can also present safety concerns for your client if another
professional misinterprets your documentation due to such errors.

Writing problem statement:

As occupational therapy practitioners, we recognize that a client’s sense of well-
being depends partly on the ability to participate in the life roles desired at home, at
work, at school, and in the community. Through various evaluation procedures, we
identify the areas of occupation impacted by a client’s condition and the factors
contributing to the functional limitation. Whenever possible, we also specify the
extent to which occupational performance is limited. It is important to note that the
client’s diagnosis is not the problem. The contributing factors may be the result of
the diagnosis, but it is our responsibility to identify those specific factors that
contribute to functional limitation. To summarize, you need to identify the following:
♦ An area of occupation
if possible, a measurement of the functional limitation
♦ A contributing factor to be addressed in occupational therapy
If possible, a measurement for the contributing factor
♦ Optional: The diagnosis causing this factor Let’s take a look at an example of a
functional problem statement: This statement has the essential elements of the area
of occupation and a contributing factor, but more specific measurable information
would be helpful in documenting progress toward goals. Based on the problem
statement above, you will not be able to show any increase in function until the
client demonstrates full active range of motion (AROM) and is independent in
dressing. Rather than saying that the client is unable to perform a given activity
independently, it is better to state the assist level needed. It is also helpful to provide
the amount of AROM that is limited.
For example: Client is unable to dress self (I) due to AROM in (B) UE. Area of
Occupation Contributing Factor
A few more examples:
♦ Child requires mod (A) to hold scissors to complete art activities in school
due to high tone in (R) UE.
♦ Veteran requires min (A) in completing toilet transfer due to trunk instability
resulting from (R) CVA.
♦ Consumer requires maximal verbal cues to complete 3-step lunch
preparation due to decreased sequencing and problem-solving skills.

SOAP Notes

S Statement:
What a client or family might say related to treatment.} May
include: complaints, feelings, attitudes expressed, concerns,
statements about goals/plans} Paraphrase or use direct quotes
Note: Not all notes contain subjective info…
The first section of the SOAP note contains subjective information obtained from the client,
giving his or her perspective on his or her condition or treatment. Subjective data are
information that cannot be verified or measured during the treatment session. In this
section, the therapist records the client’s report of limitations, concerns, and problems, as
well as what the client said that was relevant to treatment, such as significant complaints of
pain; fatigue; or other expressions of feelings, attitudes, concerns, goals, and plans. When
direct quotes are used in the subjective sections of the SOAP note, it is understood that the
statement came from the individual receiving therapy unless otherwise stated. The
information obtained from the client will be of greater significance and relevance to the rest
of your note if it is specific rather than general in nature. For instance, if the client tells you,
“My shoulder hurts,” you may question him further, asking him, “Where does it hurt?” or
“When does it hurt?” so your note can communicate more detailed information on his
condition. You may either use a direct quote or summarize what the client has said, so his
description might be written as: Client reports (R) shoulder pain when he tries to put his
shirt on. or Client states, “My right shoulder hurts when I try to put my shirt on.”

Examples of “S” Statements:

♦ “I don’t need therapy.”
♦ Resident reports pain in (R) shoulder when reaching up to comb hair.
♦ Patient asked for help when it was needed during the session.
♦ Client reports, “I keep blowing up at home and yelling at everyone, and I don’t know what
to do about it.”
♦ ‘I can’t wash the dishes or zip my coat”
♦ Veteran reports that his fingers “feel kind of dead.”
♦ Pt. reported that he needed to go meet someone and get to work when the session began.
When asked questions such as “Can you hear me?” he often responded, “I need to go.”
♦ Resident reports he feels “pretty good” now and his goal is to “get back as natural” as he
can.
♦ Consumer reports being fearful of leaving her home.
♦ Client reports that his doctor has ordered “some home care for a few days to work on
transfers.”
♦ Client reported that her shoulders fee l better after taping. “M y short-term goal is to be
able to write, and my long-term goal is to return to work.”

As part of the initial evaluation process, an occupational therapist works toward establishing
a collaborative relationship with the client by interviewing the client about his or her
concerns and priorities and developing an occupational profile. The occupational profile is
the “summary of information that describes the client’s occupational history and
experiences, patterns of daily living, interests, values, and needs. Additional information for
the occupational profile may be gathered from discussions with family or caregivers, and
through review of existing health records. In an evaluation note, the “S” may contain all or
part of the client’s occupational profile.
For 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 (I)
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 reports that her
activities are primarily sedentary, including sewing, reading, and playing cards with friends.
She says her daughter lives two blocks away and provides transportation when needed.

Sometimes the client is not able to speak or does not make any relevant comments. In such
cases, include that information in the “S” section. For example:
♦ Client unable to communicate verbally due to expressive aphasia.
♦ Client did not speak without cueing.
♦ Using her augmentative communication device, pt. reported that she wanted to be able to
take care of herself.
♦ Resident does not clearly verbalize during treatment, but smiles and nods appropriately
when asked questions. Sometimes you will include information that the family or caregiver
provided about the client if this is pertinent to the session or the client’s progress. This is
common when treating infants and very young children. For example: Mother reports
difficulty with diapering and dressing the infant, stating, “He just gets all stiff and arches his
back.”
♦ Foster parents report that child exhibits excessive energy, constantly running around the
house and jumping on furniture. They also report that child is aggressive toward foster
siblings and the family pet, and he will not remain seated at mealtimes.

O Statement:
Objective data: observable, quantifiable, measurable data
strengths and limitations (both are necessary)
Start with the positive, don’t focus just on deficits and limitations § State only facts.
No interpretations (yet…)
O section needs to describe, in detail, what was done in the tx session
Once you start looking at things with your professional eyes, they can look quite
different. Instead of seeing a child playing with a toy, now you begin to note the
child’s asymmetrical posture, his bilateral hand use, his difficulty crossing midline,
and his grasp and pinch patterns.

There are three important steps to remember when writing the “O” section of your
SOAP note:
1. Begin with a statement about the setting and purpose of the treatment session.
2. Follow the opening statement with a summary of what you observed.
3. Be professional, concise, and specific.

It explains the “where,” “what,” “how long,” and “why” about the client’s
occupational therapy services.

Examples:
1- Patient participated in 30-minute OT session in hospital room for completion of
morning bathing, dressing, and grooming routine using adaptive equipment.

2- Child participated In50 minute OT session in outpatient clinic focusing on

improving postural control and UE coordination for increased success in play
activities.
 After you have established the setting and purpose, you will discuss the interventions
that were completed and the client’s response to those interventions.

♦ Chronologically. Discuss each treatment event in the order it occurred during the
treatment session.
♦ Categorically. Organize the information according to categories. The categories you
select will vary depending on the client and the purpose of the treatment session.
You can refer to the Framework-II for potential categories. For example, it may be
helpful to organize the objective information by areas of occupation, client factors, or
performance skills
Chronologically:
Client participated in anger management group fo r 45 minutes today to improve social
interaction skills and ability to maintain employment. Client initially required verbal
prompting from nursing staff and security aides to attend group. He displayed displeasure at
being asked to attend the group by using profanity. During the group, client related 2
instances in which individuals on the unit consistently bother him, and discussed the way he
usually handles the situation. Peer feedback was given on other possible ways he might
handle the situation. Client indicated that he would consider these alternatives next time a
bothersome situation arises.
Hand Function and Strength: Adequate for unscrewing lids, cracking egg, and opening muffin
box (T). Client able to use necessary tools for carrying out task (T). Client able to set oven
dial and put muffins in oven (I).
Activity Tolerance: Client (D took a 3-minute break after ~ 20 minutes of activity.
Cognition: Client able to respond to verbal instruction and questions with correct response
3/3 times. Client said that she did not think it would be safe for her to take the muffins out
of the oven. Client able to problem solve (T) about repositioning her w/c 75% of tx. time.

• Focus on pt. response, not just what therapist did

“OT provided neuro re-education to the L UE” vs. “Pt tolerated neuro re-education to
L UE, demonstrating shoulder flexion to 90° with synergies.”
• Focus on the outcome, not the only intervention
Patient worked on placing pegs into a pegboard” vs. “Pt worked on tripod pinch in
order to be able to grasp objects needed for ADL tasks”
• Not being specific enough about assist levels “Patient required assistance to done
shirt” vs. “Patient required minimal assistance to don shirt.

A Statement:
Assessment: your professional conclusions about the preceding subjective and objective
data
• No new information presented
• Demonstrates your clinical reasoning
• Conclusion about progress or lack of progress
• Evidence that tx was effective
• Inconsistencies between subjective report and objective findings
• Assessment of factors/areas of performance not WFL
• Justifies continuation of services or discharge
The third section of the note is the assessment, which contains the therapist’s appraisal of
the client’s progress, occupational limitations, and expected benefit from OT intervention. In
the assessment section of the note, you will use your clinical reasoning to interpret the
meaning of the data you have presented in the “ S” and “0 ” sections. You will describe what
it means in your professional judgment and its potential impact on the client’s ability to
engage in meaningful occupation. In the assessment section o f your note, you will primarily
note the 3 Ps: problems, progress, and rehab potential. You might also point out
inconsistencies, discuss emotional components, or present some reason that something was
not done as planned. Finally, the assessment section is where you justify continuation of OT
services.

O: Client was unable to remember steps necessary to complete laundry task. Client also did
not turn stove off after cooking activity.
A: Memory and sequencing changes prevent patient from being independent and safe with
home management tasks.

O: Client completed dressing routine with min Assist, but required 6 verbal cues to
remember hip precautions
A: Changes in memory are interfering with client’s ability to incorporate hip precautions into
basic self-care tasks, leading to pain.

Activity Example:
Treatment: Light meal preparation
Level of performance O: Client places her walker in the corner of the kitchen when
accessing the kitchen. Client demonstrates minimal Assistance with simple meal preparation
and required max verbal cueing for safety.
Interpretation for performance A: Client has most commonly used pots/pans in lower
cabinet, putting client at risk for falls when bending down to reach them. Client required
excessive cues for safety during activity, which may indicate the need for supervision at
home.
P statement:
Plan: outline of specific action to be taken
Includes:
Frequency: Infant will be seen 2x/wk....
Continue OT daily...
Duration: Infant will be seen 2x/wk for 2 months
Continue OT daily for 3 days
Purpose of continued therapy and/or specific interventions
Types of intervention procedures Infant will be seen 2x/wk for 2 months to address feeding
skills. Treatment to include oral desensitization and caregiver training in use of adaptive
bottles.
Updated goals (long term and short term)

Client will be seen 3x/wk for 2 wks to fit for R hand splint, establish splint wearing schedule,
and implement HEP for PROM. Upon discharge, patient will tolerate R hand splinting
schedule and demonstrate competency with HEP. • Continue skilled OT intervention 3x/wk
for 2 weeks.

Writing Goals

For example,
if your LTG is: Client will complete 3-step stove top meal preparation with modified
independence using walker by 7/15/20.
then one of your STGs might be: Client will retrieve and transport items from refrigerator to
stove using walker and wheeled cart with supervision by 7/5/20.
If your LTG is: Client will move 35# objects needed for work from table to counter without
increasing in pain by12/18/20.
then one of your STGs might be: Client will be able to lift 10# objects needed for work
without increase in pain by 12/5/20.

Ali, a 45-year-old sustained a (R) CVA a few days ago and has (L) hemiplegia. On evaluation,
you find that he is oriented, able to learn, and has a supportive wife. After talking with him
about what he would like to achieve in occupational therapy, you and he decide upon a goal
of independent upper body dressing. You believe that this is a realistic goal, provided that he
receives skilled instruction and the necessary adaptive equipment. You set a series of STGs:
Seated edge of bed, client will reach for clothing items at arm’s length with supervision to
maintain dynamic sitting by the end of the 3rd treatment session.
By the 6th treatment session, client will be able to tolerate >10 minutes of dressing activity
without rest break seated edge of bed (EOB) with supervision.
After skilled instruction, client will be able to don shirt sitting EOB using one-handed
techniques with min verbal cues by 7/10/20.
Client will be able to button shirt using a button hook with 2 or fewer verbal cues by
7/12/20.
Client will complete all upper body dressing tasks with modified independence seated EOB
by 7/15/20.

Goal writing principles :

…
 COAST method for writing goals

C (Client) : In writing treatment goals, the client is the key player.

Goals should be written in terms of what the client will do, not what the therapist will do.

For example: Client will perform.

O (Occupation) This is the specific occupation to which this goal pertains and should
relate to the problem statements that have been established.
For example: Client will perform a 3-step cooking process..

A (Assist Level) : This is where you specify the level of assistance expected, which
ultimately translates into the level of independence that the client is expected to
demonstrate.
For example: Client will perform a 3-step cooking process with 2 or fewer verbal cues for
sequencing and safety...

S (Specific Conditions): This is where you specify any other conditions under which
the client is expected to perform the desired action such as location, adaptive equipment, or
modified technique.
For example: Client will perform a 3-step cooking process with 2 or fewer verbal cues for
sequencing and safety from w/c level in rehab kitchen...

T (Timeline): This is the timeframe within which the goal is expected to be

accomplished. For a LTG, this may be the anticipated discharge date.
For example: Client will perform a 3-step cooking process with 2 or fewer verbal cues for
sequencing and safety from w/c level in rehab kitchen by 20/3/20.

C: Client will
0: feed self 50% of meal
A: with min physical (A) to scoop
S: using built-up spoon
T: within 3 tx. sessions. Within 3tx. sessions,

Examples:
client will feed self 50% of meal using built-up spoon with min physical (X)to scoop. Using
built-up spoon, client will feed self 50% of meal with min physical(A)to scoop within 3
sessions.

Client will fasten 3 buttons in 2 minutes using button hook with min verbal cues
by 5/2/11.
Pt. will complete bathing tasks seated on tub bench using long handled sponge
with supervision within 1 week.
Client will demonstrate ability to change infant’s diaper using adaptive one-
handed methods with 2 or fewer verbal cues within 2 weeks.
Within 3 days, client will demonstrate safe transfer in/out of car with
supervision while adhering to postsurgical hip precautions.
Child independently will print upper case alphabet on wide notebook paper,
demonstrating proper letter formation and staying on line, with <3 errors 75%
of attempts.
Child will copy 10 math problems from whiteboard to paper with <2 errors
and no verbal cues 80% of attempts.
Carlos independently will identify at least 2 opportunities for community
volunteer service by next group session.
Child will place 3 shapes into puzzle board with no verbal cues in 3 months