Occupational therapy SOAP note example

A treatment note for an outpatient occupational therapy session with an adult regaining hand function after a stroke. It links measures of strength and dexterity to the daily activities the client wants back.

Example SOAP note

Fictional client: Robert T., 68, eight weeks after a left-hemisphere stroke, right hand dominant, visit 5. Any likeness to a real person is a coincidence.

Subjective

Client reports he buttoned his shirt by himself this morning "for the first time, slowly." Still asks his wife to cut his food.

Feels tired after about 30 minutes of activity. Goals: cook simple meals and get back to woodworking.

Objective

Grip strength (dynamometer): right 14 kg (evaluation 9 kg), left 32 kg.

Nine-Hole Peg Test: right 48 seconds (evaluation 71 seconds).

Box and Block Test: right 32 blocks a minute (evaluation 22), left 52.

Upper body dressing: buttoned a five-button shirt in 3 minutes 40 seconds with set-up only.

Feeding: cut soft food with a rocker knife; minimal assistance to steady the plate.

Fine motor training, 20 minutes: soft therapy putty, pegboard, picking up coins.

ADL training, 20 minutes: cutting food, opening jars with a non-slip mat.

Home program review, 5 minutes. Two rest breaks taken.

Assessment

Right hemiparesis after a stroke, affecting the dominant side (I69.351).

Grip up 5 kg and the Nine-Hole Peg Test 23 seconds faster since evaluation; the gains carry over to dressing.

Fine motor speed and using both hands together still limit feeding and meal preparation.

Short-term goal 1 (upper body dressing with set-up only): met. Short-term goal 2 (cut food with adaptive equipment, modified independent): progressing.

Continues to benefit from skilled occupational therapy to progress ADL independence safely.

Plan

Continue twice a week for four weeks.

Next session: graded kitchen tasks (making a sandwich, using a jar opener); progress putty to medium resistance.

Recommended a rocker knife and non-slip mat for home; showed his wife how to set them up.

Home program: putty exercises 10 minutes twice a day, and pegboard practice.

Reassess grip, Nine-Hole Peg Test and Box and Block Test at visit 10.

Why this note works

  • The measures (grip, Nine-Hole Peg Test, Box and Block Test) are compared with the evaluation.
  • It ties the measures to function: stronger, faster hands mean he can dress himself.
  • Level of assistance is stated precisely (set-up only, minimal assistance), which is how ADL goals are judged.
  • Caregiver training and equipment are recorded, part of what makes the therapy skilled.
  • The goals carry statuses, and the Plan sets the next reassessment.

What to include in each section

Subjective

  • What the client can and can't do at home since the last visit
  • Pain, fatigue and mood
  • Home program done; caregiver's report
  • Client's goals and valued activities

Objective

  • Standardized measures (grip, Nine-Hole Peg Test, Box and Block, COPM) with the evaluation result
  • ADL and IADL performance, with the level of assistance
  • Interventions with minutes: therapeutic activity, ADL training, fine motor, cognitive strategies
  • Adaptive equipment trialed or issued
  • Response and tolerance

Assessment

  • Diagnosis and the functional problem, with ICD-10-CM codes
  • Progress toward each goal
  • What still limits independence or safety
  • Why skilled OT is still needed

Plan

  • Frequency and duration
  • Next session's focus and progressions
  • Home program and caregiver training
  • Equipment and home modification recommendations
  • Next reassessment

Write yours with the free SOAP note template

The template opens with the occupational therapy prompts. Fill it in and download a PDF, made on your device.

Open the template

SOAP notes in CloudMedico

CloudMedico is practice management software for small practices. Choose SOAP as your visit note format in Practice settings, and every new visit's notes open with the headings Subjective, Objective, Assessment and Plan. Practices in the United States start with SOAP.

Add the visit's diagnoses from the ICD-10-CM list, and add your own visit fields for what your profession records every time, such as a pain scale or the regions treated. Each visit stays on the client's record with their appointments and invoices, and a US practice can make a superbill from the invoice.

Try CloudMedico free for 30 days

More SOAP note examples

Questions

What makes an OT note different from a PT note?

An OT note centers on occupations: the daily activities the client needs or wants to do. Measures of strength or dexterity are there to explain how they change dressing, feeding, cooking or work.

How should I document the level of assistance?

Use the same scale every time, such as independent, modified independent, set-up, supervision, and minimal, moderate or maximal assistance, so the change from visit to visit is clear.

Should an OT note include caregiver training?

Yes. Record who was trained, in what, and how well they carried it out. It shows skilled care and helps the next clinician.

Sources

Related