SOAP Notes For Occupational Therapy Template
A simple, downloadable PDF template for taking SOAP Notes in occupational therapy.
Fact Checked by Nate Lacson.
What is an Occupational Therapy SOAP Notes Template?
This occupational therapy (OT) SOAP Notes template is designed to help take comprehensive and well-structured notes during their client sessions.
The SOAP acronym is well-known around the world and used across many different healthcare settings. SOAP stands for subjective, objective, assessment and plan.
Let’s see how you can use these headings in your occupational therapy practice.
Subjective
This is where you will write down information specific to your client including their feelings, pain level, mood, or any new or progressing symptoms. Their priorities and goals for the session may also be relevant to this section and will help guide your session. If this is your first session with your patient you may record a more comprehensive history of your client, including the reason they are seeking occupational therapy services, present symptoms, medications, allergies, and past treatments.
Objective
This section is for measurable or observable facts. Your client’s response to a given task, their ability to complete a given task with or without assistance, results of a physical exam, or details you observe of their functioning may all be relevant here.
Assessment
The assessment section is where you can write down your professional opinion as an occupational therapist of the patient’s current ability or performance in relevant tasks. This summary will be based on the subjective and objective information you gathered in the first two sections.
Plan
What are the next steps for your client? Include specific details like any resources you provided, any exercises or tasks you left them to practice between sessions or anything you will be focussing on in particular in your client’s following sessions.
For more information on SOAP Notes head to Carepatron’s detailed page on SOAP Notes.
Occupational Therapy SOAP Notes Templates
Check out these free SOAP Notes For Occupational Therapy Templates to help simplify your clinical notes.
How to Use this SOAP Note Template for Occupational Therapy
Our occupational therapy SOAP Notes template is ready for you to download and start filling in. Just follow these simple steps to get going!
- Download the PDF template
Once you download the PDF template, you will be able to start filling it out either digitally or by printing it out and filling it out by hand- whichever method is preferred in your occupational therapy practice.
- Include patient information
Our occupational therapy SOAP Notes template has a dedicated header including patient information like their name, date of birth, and the date of your occupational therapy session with them.
- Fill out the SOAP sections
As you conduct your client’s occupational therapy session, take notes in each of the four SOAP sections as required. While you can take the notes in any order, working through the SOAP Notes template from top to bottom is one simple way to do this.
- Store your template somewhere safe
Once your template is all filled in, you’re not quite finished yet! It’s important that you store these notes somewhere accessible, secure, and safe, not just because you spent time and effort writing these notes, but also to meet your legal obligations under HIPAA. Luckily, Carepatron is a HIPAA-certified platform for you to digitally store your patient records, like the occupational therapy SOAP Notes.
Occupational Therapy SOAP Note Example
Want to see what this occupational therapy SOAP Notes template looks like once it’s completed? We’ve got you covered. This OT SOAP Notes example is a (fictional!) occupational therapy SOAP note using our SOAP Notes template, designed to illustrate to you what the finished template might look like.
In this example, Mr. John Sample is attending occupational therapy following an accident on his farm.
Download this sample occupational therapy SOAP Note template here.
Who Can Use This Occupational Therapy Template?
Our SOAP Notes for occupational therapy template is designed for occupational therapists, but would also be useful for occupational therapist assistants or occupational therapists in training.
The field of occupational therapy is very broad, and we have designed our template so it is generic enough to be used in any specialty of occupational therapy. Occupational therapists who use this occupational therapy SOAP Notes template may specialize in:
- Brain injury occupational therapy
- Pediatric occupational therapy
- Hand therapy
- Physical rehabilitation following injury
- Stroke rehabilitation
Why is this Template Useful for Occupational Therapists?
Capture all the information you need, in every session
Our OT SOAP Notes template already has the four SOAP sections set out and ready for you to use, ensuring you have the headings you need at your fingertips every time you open up your template.
Keep your notes comprehensive but readable
Using a template to structure your occupational therapy notes is a great way to ensure you cover everything you need from your patient’s session. However, another key aspect of note-taking in a healthcare setting is to ensure your notes are shareable with others in your client’s care team. Using a simply structured template, like our OT SOAP Notes template, ensures others can quickly interpret your notes and, if needed, pick up where you left off.
Structure your occupational therapy sessions
The SOAP acronym is great as not only does it serve as the headings of your notes, but it can also act as a guide for the structure of your occupational therapy session. Just work your way through the template from top to bottom and you’ll have a simple skeleton for how to guide your occupational therapy session.
Why Use Carepatron for Occupational Therapy SOAP note?
Carepatron is a fully online practice management software that makes it easy for you to access your patient’s information on the go, whether that is at a client’s home or from your home office!
Carepatron provides a HIPAA-compliant, digital way for you to store your patient’s records, such as their occupational therapy SOAP Notes, as well as a whole suite of smart ways to save you time. Schedule your client’s occupational therapy appointments, manage payments and billing, and see your week at a glance all from within Carepatron.
Our voice-to-text feature, client list system, integrated video call management, and customizable tag system give you greater control over how you manage your occupational therapy practice.
Not to mention, you can use this occupational therapy SOAP Notes template and many others from within Carepatron’s community template library.
Commonly asked questions
It can be tricky to decide whether symptoms go into the subjective or objective section. A good rule of thumb is if the patient is telling you a symptom, this goes under subjective, whereas if you observe a symptom, this goes under objective.
Occupational therapists may choose to write a more comprehensive profile of their clients during their first session. This may include more details of their social and medical background, their goals and priorities, or demographic information on your client.
While you could choose to use a more detailed and structured template for your patient’s initial consultation, we have kept this template simple, so you can definitely include all the extra information you might take in your client’s first session if you choose.
If you choose to print out this PDF and write on it by hand, anatomical diagrams may be included in any of the sections depending on the information you are trying to get across. If you wish to describe the exact location of an injury or disability as you have observed it, this would belong in the objective or assessment sections, whereas if the client is reporting information in a particular anatomical area- this would belong in the subjective section. Similarly, if you wish to include a diagram of the location of your planned intervention, this would belong in the final plan section.
