Comprehensive SOAP Note Examples for Occupational Therapy Practice

Introduction to SOAP Notes in Occupational Therapy

SOAP notes serve as the backbone of clinical documentation in occupational therapy practice. This standardised format, Subjective, Objective, Assessment, and Plan, provides a structured approach to documenting patient interactions, assessments, and treatment plans. For occupational therapists working across various practice settings, mastering SOAP note documentation is essential for effective patient care, professional communication, and reimbursement.

SOAP notes not only track patient progress but also serve as legal documents that reflect the quality and necessity of occupational therapy services. According to the American Occupational Therapy Association, proper documentation is crucial for demonstrating the value of occupational therapy interventions and supporting evidence-based practice.

Importance of SOAP Notes for Clear Communication

Well crafted SOAP notes facilitate seamless communication among healthcare team members. They provide a comprehensive snapshot of the patient’s current status, progress, and treatment plan in a format that’s universally understood by healthcare professionals.

Key benefits of effective SOAP notes include:

• Ensuring continuity of care across multiple providers.
• Creating a legal record of services provided.
• Supporting insurance reimbursement claims.
• Tracking patient progress over time.
• Facilitating evidence-based clinical decision making.

Research published in the Journal of Occupational Therapy Education highlights that clear documentation significantly improves interdisciplinary collaboration and patient outcomes in rehabilitation settings.

Detailed SOAP Note Examples

The following examples demonstrate how to effectively document various occupational therapy scenarios using the SOAP format. Each example highlights the key components and specific considerations for different practice areas.

1. Stroke Rehabilitation

Subjective: 68-year-old male, 3 weeks post-right MCA stroke, reports, “I’m frustrated that I can’t use my left arm to dress myself.” Patient expresses high motivation to regain independence in self-care activities. Reports fatigue after 30 minutes of activity.

Objective: Left upper extremity strength: 2/5 proximal, 1/5 distal. Barthel Index Score: 45/100, indicating moderate dependence in ADLs. Moderate left visual neglect observed during reading task. Requires moderate assistance for upper body dressing and maximum assistance for lower body dressing.

Assessment: Patient presents with left hemiparesis and visual-perceptual deficits secondary to right MCA stroke, resulting in significant limitations in self-care activities. Patient demonstrates good awareness of deficits and strong motivation, which are positive prognostic indicators.

Plan: Continue OT 3x weekly focusing on: 1) Upper extremity neuromuscular re-education using task-oriented approach, 2) ADL training with adaptive techniques, 3) Visual scanning strategies for left neglect. Recommend mirror therapy home program to supplement in-clinic interventions.

2. Paediatrics Developmental Delay

Subjective: Parents of 4-year-old female report concerns about fine motor skills: “She struggles with holding crayons and using scissors compared to peers.” Parents note difficulties with fasteners and utensil use during mealtimes. Child reportedly enjoys sensory play with modelling clay.

Objective: Peabody Developmental Motor Scales-2 Fine Motor Quotient: 72 (Below Average). Demonstrates immature pencil grasp (palmar supinate). Unable to cut along straight line. Difficulty with bilateral coordination during bead stringing. Sensory Profile-2 indicates sensory seeking behaviours.

Assessment: Patient presents with developmental coordination disorder affecting fine motor skills and resulting in difficulties with school readiness activities and self-care tasks. Sensory processing differences appear to impact motor planning and execution.

Plan: OT 2x weekly for 45-minute sessions focusing on: 1) Grasp development through graded fine motor activities, 2) Scissor skills progression, 3) Sensory integration techniques to support motor planning. Home program to include play-based fine motor activities to reinforce therapy goals.

3. Hand Therapy Post-Surgery

Subjective: 35-year-old male, 4 weeks post-flexor tendon repair of right long finger, reports compliance with home exercise program. Rates pain as 3/10 during exercises, 1/10 at rest. Expresses concern about returning to work as a computer programmer.

Objective: AROM of right long finger: MCP 0-45°, PIP 0-30°, DIP 0-20°. PROM within post-operative protocol limits. Oedema: +1 in affected digit. Scar is well-approximated with mild adherence to underlying tissue. Light touch sensation intact throughout.

Assessment: Patient is progressing as expected following flexor tendon repair. ROM limitations are consistent with stage of healing. Minimal oedema and well-healing scar are positive indicators. Current functional limitations impact typing and other fine motor tasks required for work.

Plan: Continue OT 2x weekly: 1) Progress AROM exercises within protocol guidelines, 2) Initiate tendon gliding exercises, 3) Scar management with silicone gel and massage techniques, 4) Oedema control through retrograde massage. According to the American Society for Surgery of the Hand, adherence to controlled mobilisation protocols is critical for optimal outcomes.

4. Cognitive Rehabilitation

Subjective: 42-year-old female, 2 months post-moderate TBI, reports, “I forget what I’m doing in the middle of tasks.” Notes increased fatigue and headaches with cognitive exertion. Expresses frustration with inability to return to work as an accountant.

Objective: MoCA Score: 22/30 (mild cognitive impairment). Trail Making Test Part B: 180 seconds (impaired). Demonstrates difficulty with multi-step tasks, requiring verbal cues to complete kitchen task assessment. Attention span limited to 15-20 minutes before noticeable increase in errors.

Assessment: Patient demonstrates cognitive-communication deficits secondary to TBI, particularly affecting executive functioning, attention, and memory. These deficits significantly impact IADL performance and vocational activities.

Plan: OT 2x weekly focusing on: 1) Cognitive strategies training (external aids, organizational systems), 2) Graduated attention tasks with increasing complexity, 3) IADL task practice with fading cues. Recommend cognitive rest strategies and energy conservation techniques to manage fatigue. Consider AI documentation tools to support return to work planning.

5. Activities of Daily Living (ADL) Training

Subjective: 72-year-old female, 1 week post-left total hip replacement, reports, “I can’t put on my pants or socks without help.” Expresses concern about managing at home alone after discharge. Motivated to regain independence in self-care.

Objective: FIM Scores: Lower body dressing 3/7 (Moderate Assistance), Toileting 4/7 (Minimal Assistance). Hip ROM within post-op limits. Demonstrates proper use of hip precautions during transfers but forgets precautions during dressing tasks. Requires verbal cues to use adaptive equipment.

Assessment: Patient presents with ADL performance deficits secondary to recent hip replacement and movement precautions. Current level of assistance and adaptive equipment needs suggest potential for safe discharge home with appropriate supports and continued therapy.

Plan: Daily OT until discharge: 1) Lower body dressing training using reacher and sock aid, 2) Toilet transfer training with elevated commode, 3) Car transfer practice, 4) Home safety evaluation prior to discharge. Provide illustrated guide for hip precautions and equipment use.

6. Sensory Processing Disorder

Subjective: Parents of 6-year-old male report challenges with classroom participation: “He can’t sit still during circle time and melts down when asked to wear certain clothes.” Child reports disliking “sticky” art materials and loud noises in the cafeteria.

Objective: Sensory Profile-2 indicates definite differences in sensory seeking and sensory sensitivity categories. Observed to seek vestibular input through constant movement. Demonstrates tactile defensiveness with certain textures. Difficulty with transitions between activities, requiring additional time and preparation.

Assessment: Child presents with sensory processing disorder characterized by sensory seeking and sensory over-responsivity, significantly impacting school participation and daily routines. Behavioral responses to sensory input affect social interactions and learning opportunities.

Plan: OT 1x weekly and consultation with school: 1) Sensory integration activities focusing on vestibular and proprioceptive input, 2) Gradual desensitisation to challenging textures, 3) Development of sensory diet for home and classroom, 4) Collaboration with teacher on environmental modifications to support regulation.

7. Geriatric Fall Prevention

Subjective: 84-year-old female reports two falls in the past month: “I’m afraid to take a shower by myself now.” States fear of falling has led to decreased activity levels and social isolation. Lives alone in single-story home with two steps at entry.

Objective: Berg Balance Scale: 32/56 (High Fall Risk). TUG Test: 18.5 seconds (increased fall risk). Home assessment reveals poor lighting, loose rugs, and lack of bathroom grab bars. Demonstrates inconsistent use of quad cane during ambulation.

Assessment: Patient presents with increased fall risk due to impaired balance, environmental hazards, and fear of falling. Current activity limitations and participation restrictions negatively impact quality of life and may lead to further deconditioning.

Plan: OT 2x weekly for 6 weeks: 1) Balance activities in various functional contexts, 2) Home safety modifications including grab bar installation and improved lighting, 3) Energy conservation techniques for ADLs, 4) Fear of falling management strategies. According to the CDC’s STEADI initiative, multifactorial interventions show the greatest efficacy for fall prevention.

8. Upper Extremity Rehabilitation

Subjective: 58-year-old male, 8 weeks post-right rotator cuff repair, reports improved ability to perform waist-level activities but continued difficulty with overhead reaching: “I still can’t put dishes away in the upper cabinets.” Pain rated 2/10 at rest, 5/10 with end-range movement.

Objective: Right shoulder AROM: flexion 140°, abduction 120°, external rotation 45°. Strength testing: flexion 4/5, abduction 3+/5, external rotation 3/5. Mild scapular dyskinesis observed during elevation. Decreased endurance with repetitive overhead activities.

Assessment: Patient demonstrates improved AROM and strength following rotator cuff repair but continues to present with functional limitations in overhead activities and endurance. Current status is consistent with expected timeline for post-operative recovery.

Plan: Continue OT 2x weekly: 1) Progress ROM through end-range stretching within pain limits, 2) Advance strengthening program with focus on rotator cuff and scapular stabilisers, 3) Functional training for overhead activities with proper mechanics, 4) Work simulation for planned return to construction supervision. For additional resources, see detailed SOAP note samples for upper extremity conditions.

Conclusion: Best Practices for SOAP Notes

Effective SOAP notes in occupational therapy should be concise, specific, and objective while still capturing the unique needs and progress of each patient. When documenting, remember these key principles:

• Be specific – Include measurable data and concrete observations.
• Stay relevant – Focus on information that impacts clinical decision-making.
• Document functional outcomes – Connect improvements to meaningful activities.
• Use professional terminology – Maintain clinical language while avoiding jargon.
• Consider reimbursement requirements – Include elements necessary for justifying services.

With the growing documentation demands in healthcare, many occupational therapists are exploring technology solutions to streamline the documentation process while maintaining quality. AI-powered tools like AllyScribe can help reduce documentation time while ensuring comprehensive and compliant SOAP notes.

By following these examples and best practices, occupational therapists can create documentation that effectively communicates patient care, supports clinical reasoning, and meets professional and regulatory standards.

References

[1] American Occupational Therapy Association – “Documentation in Practice” – https://www.aota.org/practice/documentation

[2] Journal of Occupational Therapy Education – “Documentation Quality in Occupational Therapy Practice” – https://www.tandfonline.com/doi/abs/10.3109/07380577.2015.1044690

[3] National Center for Biotechnology Information – “Mirror Therapy for Upper Limb Rehabilitation” – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6367611/

[4] American Society for Surgery of the Hand – “Flexor Tendon Injuries” – https://www.assh.org/handcare/condition/flexor-tendon-injuries

[5] Centres for Disease Control and Prevention – “STEADI Initiative” – https://www.cdc.gov/steadi/index.html