SOAP Notes for Occupational Therapy

Sep 3, 2020 12:52:50 PM

No one gets into occupational therapy for the progress notes. You don’t get paid for documentation time. And it can be difficult to see how writing notes connects with your main focus of helping people and seeing them reach their potential. But progress notes are an important part of serving patients effectively. Better progress notes mean better patient health outcomes since they help you see progress on paper, in black and white. And if a patient’s insurer ever questions a treatment decision, your notes will help back up your choice to ensure you get reimbursed for the services you provided. 

The SOAP format is the most popular one for progress notes. And for good reason — it’s simple and effective. In this post, we’ll explore the SOAP note format and provide some pointers on how to write effective progress notes. We’ll also show you an example to give you a better idea of how SOAP notes look in the real world.

Occupational Therapy SOAP Notes Format

SOAP is an easy-to-remember acronym representing the four key components that this note-taking framework is based on. Here’s what the acronym stands for.

Subjective

SOAP notes lead off with the subjective information you gather from the patient at the start of the session. This data is qualitative in nature and includes things like how the client rates their pain today, what type of symptoms or complaints they have, and what limitations they’re currently experiencing. This section is an ideal spot to include information like the patient’s attitude toward therapy, their own treatment goals, and how they view the effectiveness of the therapy.

Objective

Now it’s time for the hard data, the main part of the progress note. It’s a fact-laden, detailed description of the session itself. List out exactly what took place and the results you achieved. For example, what exercises did you lead the patient through? What types of special equipment or assistance was needed? How did they respond to the treatment? Was progress made? What new functional activities did you get started on? The objective part of the note is also the place to list your observations and the results of any measurements you took and/or assessments you administered.

Assessment

In this section, you’ll spell out your professional interpretation and opinion on the patient’s progress to date. You’ll provide an update on where the patient is in relation to their ultimate treatment goal and what needs to happen next to move the ball forward. If the current treatment plan should be adjusted, jot down what needs to be changed and why. If progress isn’t being made, list the factors that are making it difficult to move forward (such as lack of patient participation). Wrap up by stating why therapy should continue, noting current functioning deficits that justify additional sessions.

Plan

Now you’ll lay out the future course of action. Identify what you expect to accomplish when you meet with the patient for the next session. If you plan to use any specific types of exercises, list them here. If you recommend changes or additions to any progressions to a new task, include that here as well.

Guidelines for Better Notes

Using the SOAP format will help streamline the note-taking process, but we have a few other tips that will both elevate the quality of your progress notes and shorten the amount of time it takes to write them.

1. Deploy a Template 

Using a template guides your structure and flow so you can focus on the information that needs to go into the progress notes rather than how to arrange it. They also help ensure consistency. Filling in a template is always quicker than writing up something from scratch. Keep a template saved in your progress note-taking software. If you prefer writing progress notes out by hand, keep a stack of hard copy templates handy.

2. Use Action Words

Action words bring a sense of clarity to your writing. They provide an exactness that helps supervisors, caregivers, and insurers gain a better understanding of the type of services you provided. Action words also sharpen your focus, helping you to cut down on unnecessary verbiage that can bog down a note.

3. Focus on Relevant Details

Include enough detail about the session and your treatment that, if another therapist unfamiliar with that patient filled in for you, they’d have a reasonable idea of where to begin. But don’t waste time providing irrelevant information. Sticking closely to the critical details can be a huge timesaver. With some practice, you’ll be surprised at how much information can fit into just 2-3 paragraphs.

3. Establish SMART Goals 

SMART goals are those that are specific, measurable, attainable, relevant, and time-based. This way of thinking about goals helps you more clearly define just what it is you’re trying to accomplish with a patient and ensure you’re able to reach them.

4. Don’t Rely on Copy/Paste

It’s tempting to speed up the process of note-taking by cutting and pasting, but this approach isn’t usually effective. Every appointment is unique, so you’ll want to create progress notes that are appropriate for each session. 

5. Don’t Wait

When you have a busy daily schedule, it’s easy to fall behind on your progress notes. But the longer you wait, the more difficult it will be to remember important details. So the more time that passes between your session and when you document it, the longer it will take you to write your notes. Sooner rather than later is a time-saver.

6. Make Sure Notes are Legible

If you’re taking progress notes by hand, make sure what ends up on paper can be easily deciphered. If you’re one of the many people whose handwriting isn’t the best, it may be time to start typing your notes instead. Insurance reviewers, supervisors, caretakers, and other practitioners rely on progress notes to make important decisions regarding your clients’ care. Ideally, progress notes should be typed out and stored electronically.

Occupational Therapy SOAP Notes Example

So what does a SOAP note actually look like? Here are a couple of examples. 

Today, the patient is presenting with 5/10 knee pain following her total knee replacement three weeks ago. She reports performing her home exercise program daily and says that she can now bend down enough to reach her bottom dresser drawer. She is upbeat about her progress, but says that she is still experiencing radiating symptoms in the evening. She continues to use naproxen daily. Improved range of motion and stability of her left leg confirms that her use of her home exercise plan is improving her range of motion and strength. Add stability exercises to home exercise program to stabilize patient’s left leg in the new range. Decrease OT frequency from 3x/week to 2x/week as tolerated.”

Notice that this progress note isn’t especially lengthy. It wouldn’t require a lot of time to write. The main challenge of writing an effective progress note is the focused attention that goes into it. For example, the first section describes the specifics of what the patient reported during the session. The second section identifies the therapist’s observations of the effects of the home exercise program. The third offers the therapist’s professional recommendation on how the home exercise program should be modified. And the fourth shows the plan for the next few sessions.

SOAP Takes the Pain Out of Progress Notes

Using the SOAP format won’t make progress note-taking as enjoyable as the therapy services you provide, but it will simplify the process and make it less painful. By capturing client progress data using an easy-to-remember format, you’ll spend less time in front of a computer screen and more time in front of patients.

The SOAP format is the most popular one for progress notes. And for good reason — it’s simple and effective. In this post, we’ll explore the SOAP note format and provide some pointers on how to write effective progress notes. We’ll also show you an example to give you a better idea of how SOAP notes look in the real world.

Occupational Therapy SOAP Notes Format

SOAP is an easy-to-remember acronym representing the four key components that this note-taking framework is based on. Here’s what the acronym stands for.

Subjective

SOAP notes lead off with the subjective information you gather from the patient at the start of the session. This data is qualitative in nature and includes things like how the client rates their pain today, what type of symptoms or complaints they have, and what limitations they’re currently experiencing. This section is an ideal spot to include information like the patient’s attitude toward therapy, their own treatment goals, and how they view the effectiveness of the therapy.

Objective

Now it’s time for the hard data, the main part of the progress note. It’s a fact-laden, detailed description of the session itself. List out exactly what took place and the results you achieved. For example, what exercises did you lead the patient through? What types of special equipment or assistance was needed? How did they respond to the treatment? Was progress made? What new functional activities did you get started on? The objective part of the note is also the place to list your observations and the results of any measurements you took and/or assessments you administered.

Assessment

In this section, you’ll spell out your professional interpretation and opinion on the patient’s progress to date. You’ll provide an update on where the patient is in relation to their ultimate treatment goal and what needs to happen next to move the ball forward. If the current treatment plan should be adjusted, jot down what needs to be changed and why. If progress isn’t being made, list the factors that are making it difficult to move forward (such as lack of patient participation). Wrap up by stating why therapy should continue, noting current functioning deficits that justify additional sessions.

Plan

Now you’ll lay out the future course of action. Identify what you expect to accomplish when you meet with the patient for the next session. If you plan to use any specific types of exercises, list them here. If you recommend changes or additions to any progressions to a new task, include that here as well.

Guidelines for Better Notes

Using the SOAP format will help streamline the note-taking process, but we have a few other tips that will both elevate the quality of your progress notes and shorten the amount of time it takes to write them.

1. Deploy a Template 

Using a template guides your structure and flow so you can focus on the information that needs to go into the progress notes rather than how to arrange it. They also help ensure consistency. Filling in a template is always quicker than writing up something from scratch. Keep a template saved in your progress note-taking software. If you prefer writing progress notes out by hand, keep a stack of hard copy templates handy.

2. Use Action Words

Action words bring a sense of clarity to your writing. They provide an exactness that helps supervisors, caregivers, and insurers gain a better understanding of the type of services you provided. Action words also sharpen your focus, helping you to cut down on unnecessary verbiage that can bog down a note.

3. Focus on Relevant Details

Include enough detail about the session and your treatment that, if another therapist unfamiliar with that patient filled in for you, they’d have a reasonable idea of where to begin. But don’t waste time providing irrelevant information. Sticking closely to the critical details can be a huge timesaver. With some practice, you’ll be surprised at how much information can fit into just 2-3 paragraphs.

3. Establish SMART Goals 

SMART goals are those that are specific, measurable, attainable, relevant, and time-based. This way of thinking about goals helps you more clearly define just what it is you’re trying to accomplish with a patient and ensure you’re able to reach them.

4. Don’t Rely on Copy/Paste

It’s tempting to speed up the process of note-taking by cutting and pasting, but this approach isn’t usually effective. Every appointment is unique, so you’ll want to create progress notes that are appropriate for each session. 

5. Don’t Wait

When you have a busy daily schedule, it’s easy to fall behind on your progress notes. But the longer you wait, the more difficult it will be to remember important details. So the more time that passes between your session and when you document it, the longer it will take you to write your notes. Sooner rather than later is a time-saver.

6. Make Sure Notes are Legible

If you’re taking progress notes by hand, make sure what ends up on paper can be easily deciphered. If you’re one of the many people whose handwriting isn’t the best, it may be time to start typing your notes instead. Insurance reviewers, supervisors, caretakers, and other practitioners rely on progress notes to make important decisions regarding your clients’ care. Ideally, progress notes should be typed out and stored electronically.

Occupational Therapy SOAP Notes Example

So what does a SOAP note actually look like? Here are a couple of examples. 

Today, the patient is presenting with 5/10 knee pain following her total knee replacement three weeks ago. She reports performing her home exercise program daily and says that she can now bend down enough to reach her bottom dresser drawer. She is upbeat about her progress, but says that she is still experiencing radiating symptoms in the evening. She continues to use naproxen daily. Improved range of motion and stability of her left leg confirms that her use of her home exercise plan is improving her range of motion and strength. Add stability exercises to home exercise program to stabilize patient’s left leg in the new range. Decrease OT frequency from 3x/week to 2x/week as tolerated.”

Notice that this progress note isn’t especially lengthy. It wouldn’t require a lot of time to write. The main challenge of writing an effective progress note is the focused attention that goes into it. For example, the first section describes the specifics of what the patient reported during the session. The second section identifies the therapist’s observations of the effects of the home exercise program. The third offers the therapist’s professional recommendation on how the home exercise program should be modified. And the fourth shows the plan for the next few sessions.

SOAP Takes the Pain Out of Progress Notes

Using the SOAP format won’t make progress note-taking as enjoyable as the therapy services you provide, but it will simplify the process and make it less painful. By capturing client progress data using an easy-to-remember format, you’ll spend less time in front of a computer screen and more time in front of patients. 

The SOAP format is the most popular one for progress notes. And for good reason — it’s simple and effective. In this post, we’ll explore the SOAP note format and provide some pointers on how to write effective progress notes. We’ll also show you an example to give you a better idea of how SOAP notes look in the real world.

Occupational Therapy SOAP Notes Format

SOAP is an easy-to-remember acronym representing the four key components that this note-taking framework is based on. Here’s what the acronym stands for.

Subjective

SOAP notes lead off with the subjective information you gather from the patient at the start of the session. This data is qualitative in nature and includes things like how the client rates their pain today, what type of symptoms or complaints they have, and what limitations they’re currently experiencing. This section is an ideal spot to include information like the patient’s attitude toward therapy, their own treatment goals, and how they view the effectiveness of the therapy.

Objective

Now it’s time for the hard data, the main part of the progress note. It’s a fact-laden, detailed description of the session itself. List out exactly what took place and the results you achieved. For example, what exercises did you lead the patient through? What types of special equipment or assistance was needed? How did they respond to the treatment? Was progress made? What new functional activities did you get started on? The objective part of the note is also the place to list your observations and the results of any measurements you took and/or assessments you administered.

Assessment

In this section, you’ll spell out your professional interpretation and opinion on the patient’s progress to date. You’ll provide an update on where the patient is in relation to their ultimate treatment goal and what needs to happen next to move the ball forward. If the current treatment plan should be adjusted, jot down what needs to be changed and why. If progress isn’t being made, list the factors that are making it difficult to move forward (such as lack of patient participation). Wrap up by stating why therapy should continue, noting current functioning deficits that justify additional sessions.

Plan

Now you’ll lay out the future course of action. Identify what you expect to accomplish when you meet with the patient for the next session. If you plan to use any specific types of exercises, list them here. If you recommend changes or additions to any progressions to a new task, include that here as well.

Guidelines for Better Notes

Using the SOAP format will help streamline the note-taking process, but we have a few other tips that will both elevate the quality of your progress notes and shorten the amount of time it takes to write them.

1. Deploy a Template 

Using a template guides your structure and flow so you can focus on the information that needs to go into the progress notes rather than how to arrange it. They also help ensure consistency. Filling in a template is always quicker than writing up something from scratch. Keep a template saved in your progress note-taking software. If you prefer writing progress notes out by hand, keep a stack of hard copy templates handy.

2. Use Action Words

Action words bring a sense of clarity to your writing. They provide an exactness that helps supervisors, caregivers, and insurers gain a better understanding of the type of services you provided. Action words also sharpen your focus, helping you to cut down on unnecessary verbiage that can bog down a note.

3. Focus on Relevant Details

Include enough detail about the session and your treatment that, if another therapist unfamiliar with that patient filled in for you, they’d have a reasonable idea of where to begin. But don’t waste time providing irrelevant information. Sticking closely to the critical details can be a huge timesaver. With some practice, you’ll be surprised at how much information can fit into just 2-3 paragraphs.

3. Establish SMART Goals 

SMART goals are those that are specific, measurable, attainable, relevant, and time-based. This way of thinking about goals helps you more clearly define just what it is you’re trying to accomplish with a patient and ensure you’re able to reach them.

4. Don’t Rely on Copy/Paste

It’s tempting to speed up the process of note-taking by cutting and pasting, but this approach isn’t usually effective. Every appointment is unique, so you’ll want to create progress notes that are appropriate for each session. 

5. Don’t Wait

When you have a busy daily schedule, it’s easy to fall behind on your progress notes. But the longer you wait, the more difficult it will be to remember important details. So the more time that passes between your session and when you document it, the longer it will take you to write your notes. Sooner rather than later is a time-saver.

6. Make Sure Notes are Legible

If you’re taking progress notes by hand, make sure what ends up on paper can be easily deciphered. If you’re one of the many people whose handwriting isn’t the best, it may be time to start typing your notes instead. Insurance reviewers, supervisors, caretakers, and other practitioners rely on progress notes to make important decisions regarding your clients’ care. Ideally, progress notes should be typed out and stored electronically.

Occupational Therapy SOAP Notes Example

So what does a SOAP note actually look like? Here are a couple of examples. 

Today, the patient is presenting with 5/10 knee pain following her total knee replacement three weeks ago. She reports performing her home exercise program daily and says that she can now bend down enough to reach her bottom dresser drawer. She is upbeat about her progress, but says that she is still experiencing radiating symptoms in the evening. She continues to use naproxen daily. Improved range of motion and stability of her left leg confirms that her use of her home exercise plan is improving her range of motion and strength. Add stability exercises to home exercise program to stabilize patient’s left leg in the new range. Decrease OT frequency from 3x/week to 2x/week as tolerated.”

Notice that this progress note isn’t especially lengthy. It wouldn’t require a lot of time to write. The main challenge of writing an effective progress note is the focused attention that goes into it. For example, the first section describes the specifics of what the patient reported during the session. The second section identifies the therapist’s observations of the effects of the home exercise program. The third offers the therapist’s professional recommendation on how the home exercise program should be modified. And the fourth shows the plan for the next few sessions.

SOAP Takes the Pain Out of Progress Notes

Using the SOAP format won’t make progress note-taking as enjoyable as the therapy services you provide, but it will simplify the process and make it less painful. By capturing client progress data using an easy-to-remember format, you’ll spend less time in front of a computer screen and more time in front of patients. 

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