SOAP Notes

SOAP refers to a common template healthcare providers use to document sessions or evaluations. Although different work settings include different information in their SOAP notes, the following are some general guidelines for what a SOAP note should (and should not) include.

Overview & Purpose of SOAP

In the professional world, a SOAP note serves two purposes.

What is Included in a SOAP Note

S-Subjective

O-Objective

A-Assessment

P-Plan

S-Subjective

Subjective means personal and not measurable. The S section is the place to report anything the client says or feels that is relevant to their session or case. This includes any report of limitations, concerns, and problems. Often living situations and personal history (ex. PMH or Occupational Profile) are also included in the S section. [NOTE: This does not include any answers to an evaluation or screening such as pain scale.]

• Ex. Client reported _____________ problem, feeling, action, etc.

O-Objective

Objective means that it is measurable and observable. In this section, you will report anything you and the client did; scores for screenings, evaluations, and assessments; and anything you observed. The O section is for facts and data. The O section is NOT the place for opinions, connections, interpretations, etc.

The O section might begin with an introductory sentence outlining how long the session was.

• Ex. Client participated in ____minute session in _______setting for skilled instruction/intervention in _____________.

Sometimes, the O section then gives an overview statement summarizing observations and client deficits. This is optional.

• Ex. Client presents with ___________ (disease, disability, deficit, etc.).

Next is the most important part of the O section—what happened and what you observed. There are multiple ways to organize an O section.

1. Chronologically
   1. This might be the easiest way to organize it, especially if you are new to SOAP notes.
   2. Chronological order means you write what happened in the order it happened.
      1. Ex. First the client…..Second, the client…….Next, the client…..
   3. If you organize it chronologically, make sure to include all treatments and relevant observations but remember that you do not have to include every detail of what happened.
2. Categorically
   1. Categorical means organizing the O section according to categories of things that you and the client did or that you observed.
      1. Ex. Category/Deficit #1
         1. Example 1
         2. Example 2
      2. Category #2
         1. Example 3
         2. Example 4
   2. If you organize it categorically, sometimes it is helpful to group things into broad categories because there may be overlap between one section and another.
3. Evaluation Findings
   1. If the session was an evaluation, the SOAP note may look a little different
   2. An evaluation SOAP note must include all scores from the eval. This could include:
      1. Summary of Screening results
      2. Assessment/Test/Evaluation results
      3. Pictures
      4. Observations during evaluation
   3. Evaluation scores can be listed in bullet points or in paragraph form.
      1. Ex. Name of Assessment
         1. Category: Result
4. Observations
   1. Sometimes it makes sense to incorporate observations throughout, but some people find it helpful to create a section in their O-section for observations

A-Assessment

The A section is where you describe and explain why things happened and what might be going on. This is the appropriate place for informed opinions, theories, explanation, and (last but not least) interpretations! The most important thing to remember is that the A section is where you make sense of what you wrote in the O section and S section. It should not include any new information, just like your O section should not include anything besides facts.

Many A sections include 3 P’s plus needs:

1. Problem or Cause-Effect statements
   1. These statements provide an interpretation and explanations of patient’s problems, of evaluation findings, and of observations.
2. A statement of progress
   1. Sometimes we can compare the scores or observations from our O section to what we have seen in the past.
   2. This is important because someone reading your SOAP note now understands whether your O section shows the patient is making progress or not
3. A statement of potential
   1. While it is easy to focus on the problems and issues, we also want to highlight things in the previous section that indicate the potential this client has.
   2. This could include the client’s strengths, their support system, their attitude, etc.
4. A summary statement of needs
   1. This is often a justification for services or a justification for discharge.

Example:

Problems: ______________(condition/deficit) causes client difficulty with ________________ (occupation).

Potential: Client shows rehab potential to make progress as indicated by ______________ (supports/client factors/ etc.).

Progress: Client demonstrated progress in _________ (during session or throughout therapy).

Justification of services: Client would benefit from skilled intervention/instruction focused on __________________________ (tasks/strategies for specific occupations).

P-Plan

The P section is where you answer “Now what?” Knowing the information from the sections above, write your suggestions for treatment, referrals, resources recommended, and discharge plans. For an initial eval session, this may also include long-term and short-term goals. Remember that all information in this section should connect back to your 3 P’s and Needs from your A section.

Example:

Continue tx ___min #x/wk for # wks to work on ____________ (intervention) for _____ (goal/occupations).

Referral to___________ recommended to address_______________.

Family provided with resources including _______________________.

SOAP Note Template

S- Subjective

Client reported _____________ problem, feeling, action, etc.

Client’s home situation or medical history if they share

O-Objective

Initial statement: Client participated in ____minute session in _______setting for skilled instruction/intervention in _____________.

What Client Did

What you observed

Assessment/Evaluation/Test results

A-Assessment

3 P’s and Needs

Problems: ______________(condition/deficit) causes client difficulty with ________________ (occupation).

Potential: Client shows rehab potential to make progress as indicated by ______________ (supports/client factors/ etc.).

Progress: Client demonstrated progress in _________ (during session or throughout therapy).

Needs/Justification of services: Client would benefit from skilled intervention/instruction focused on __________________________ (tasks/strategies for specific occupations).

P-Plan

Continue tx ___min #x/wk for # wks to work on ____________(skills/activities/intervention) for _____ (goal/occupations).

Referrals and Recommendations

OR Discharge plan

Example of an Initial Evaluation SOAP

S: Leo Smith is 3wks post R CVA. He reported no pain in arm throughout session, though he said his R arm felt tingly and twitched at night. He reported that he has two grandaughters who live with him and his wife, but he cannot care for them now. He is very ready to return to playing guitar for church. Client reported that he performs self-care activities well but struggles to put on jeans.

O: Client participated in 60-min initial eval session at outpatient rehab facility.

[Observations] Initial screening demonstrated flaccid hemiplegia of RUE-low muscle tone and limited AROM (only able to horizontally abduct his shoulder). Client had full PROM with some spasticity in fingers. Client also had weakness in RLE and limited ROM of ankle. Client’s sensation intact.

Evaluation Scores:

COPM

• Caring for his granddaughters-performance 1; satisfaction 1
• Playing music for church and fun- performance 1; satisfaction 1
• Driving- performance 1; satisfaction 1
• Doing household chores (trash, dishes, feeding cats)- performance 4; satisfaction 4
• Work tasks- performance 5; satisfaction 4

DASH

• 39.1 (overall) –some impairment
• 68.75 (work)- moderate impairment
• 75 (performing arts)-severe impairment

A: [Problem] R flaccid hemiplegia impairs client’s ability to perform bilateral activities such as caring for his granddaughters, playing guitar, pulling up jeans, and doing his freelance work. Limited motion in his RUE and limited ankle ROM of RLE prevent client from driving. DASH scores indicate some impairment during everyday ADLs and IADLs particularly those requiring two hands or lots of strength. DASH scores indicate moderate impairment of his work and severe impairment of performing arts because he plays guitar and is unable to strum with his right hand.

[Potential] Client demonstrates rehab potential by his ability to feel light touch and proprioception in his arm, by his positive attitude, and by having a strong social support system. His ability to complete activities with his L hand allows him to complete many ADLs and IADLs despite limitations.

[Progress] He has already demonstrated progress by regaining some movement in shoulder horizontal adduction since his stroke and some movement and weight-bearing in his R leg that allows for walking.

[Needs] Client would benefit from continued Occupational Therapy services to increase his participation in work, childcare, and music through adaptation of activities and through increasing his ability to use his RUE during bimanual tasks.

P: Continue tx 3/wk for 8 wks for skilled intervention to increase weight-bearing in RUE and RLE for driving, increase engagement of RUE during bimanual activities, increase AROM and strength of RUE through preparatory and occupation-based activities, and provide adaptive strategies for completing one-handed activities.

Referral for PT requested.

Re-evaluate COPM May 18.

Goals

LTG #1: C will play first verse of Amazing Grace on the guitar using adaptive pick and arm orthosis with set-up assistance by July 1, 2021.

STG #1: Client will play one verse of Amazing Grace on the guitar using adaptive pick and max A from his wife to move his R arm by third week.

STG #2: Client will successfully strum C then G cord using adaptive pick and arm orthosis 3/5 times by June 1.