No, it’s not a coupon for a bar of that vegan lemongrass soap you love. It’s also not a review of the melodramatic television show that you and your best friend can’t stop watching. So, what is a SOAP note? If you’re interested in occupational therapy, this is definitely a term that you should know. In this blog, we’ll cover what an occupational therapy SOAP note is and why you need to know how to write one!
What is an Occupational Therapy SOAP Note?
A SOAP note is a form of documentation that healthcare providers use. The acronym SOAP stands for the Subjective, Objective, Assessment, and Plan. Healthcare workers use SOAP notes to document important information about their patients in an organized way. This note format helps practitioners use clinical reasoning so that they effectively assess, diagnose, and treat their patients. A SOAP note also allows you as an occupational therapist to defend your treatment choices. Its simple structure is intended to be clear and concise so that the reader can understand it quickly and easily.
Occupational Therapy SOAP Note Structure
Now that you know what an occupational therapy SOAP note is, let’s explore its components. Proper documentation is essential to occupational therapy, but it can often be a tedious process. So, knowing the basics of how to write a SOAP note should be a priority for any occupational therapist in training.
Continue reading as we break down each letter in the acronym SOAP.
Subjective
Remember that this document needs to provide as much information as possible about your patients. To do this effectively, think of each section as a part of a larger narrative. For the subjective segment, you need to preface your patient’s “story” by using any feedback that they communicate to you. You can also use any relevant information that you gather from the patient’s relatives or their multidisciplinary team. This feedback can include how the patient feels and what they hope to achieve through their treatment. While this section should be thorough, don’t overdo it. Make sure that any information you include serves to explain the patient’s situation.
Objective
This section of your occupational therapy SOAP note should include anything that you’ve observed about your patient. Because of this, it will often be the longest portion of your SOAP note. You should include details such as the results of manual muscle tests, your patient’s level of independence and their range of motion, and any other objective measurements related to their diagnosis. Once you have recorded all of the necessary information, you can move onto the next section of your SOAP note.
Analysis
This section should assess your patient’s situation by synthesizing the subjective and objective information you’ve gathered so far. Use this analysis to summarize your clinical reasoning and discuss how all of the information is related. You should also use your analysis to talk about how your care will help the patient achieve their treatment goals. Don’t be afraid to showcase your knowledge and experience with this paragraph. You put in countless hours to complete your coursework and become an occupational therapist, so now it’s time to put all of the effort to use!
Plan
Once you have outlined your analysis, it’s time to talk about what needs to be done. In this section, you must think ahead when it comes to a care plan and how this plan may change throughout the course of your treatment. A few examples of what you should write are any updates to your treatment plan, additional assessments, future check-ins, and recommended discharge dates. As we said before, these final statements should be concise without omitting any crucial details.
Learning the art of the occupational therapy SOAP note takes time. Luckily, there are plenty of other resources that you can use to learn about SOAP notes. You can get feedback from your colleagues or even look up examples online! Just remember that it’s important to keep practicing and learning from any mistakes that you make.
October 29, 2020
Thank you!