We have had many people ask us about writing SOAP notes! SOAP notes can seem very overwhelming and confusing to write… we know from experience. Truth be told, when you enter the workforce you will likely be able to write a SOAP note with your own little spin to it and it isn’t as knit picky than when you’re in school (at least in most cases). Don’t get me wrong, it’s a great way to get a foundational grasp on the general process of documentation and necessary to include certain things for reimbursement; however, don’t get too hung up on creating the most perfect, detailed note that takes you thirty minutes. Capturing the most important takeaways from the session is all you need. So don’t stress!
Importance of writing SOAP notes: legal issues aka CYA (look it up if you don’t know;)), reimbursement, documents specific data and statistics from assessments and following progress/regressions as well. If you handed your note to a therapist that was taking over for that client or seeing them the next time, they should be able to pick up exactly where you left off and understand just where that patient was at as of the previous session. In some settings, the format of SOAP notes may look very different. The general concept is the same, but depending on the documentation system, the layout may be formatted differently and use interchangeable terminology asking for the same content. These days, most documentation is all electronic and there will be an option for you to automatically sign and date your note. However, if you find yourself writing out notes on paper, it is imperative that you sign and date your note. Writing notes is an important skill to have, but expect to adapt to different types of documentation systems!
That being said, we want to provide you with some tips for SOAP note writing and give you a few examples of what our notes generally look like as we each work in different settings.
Note Examples
*None of these notes are based on real patient cases. All information has been made up and is not in violation of any HIPAA laws.
Acute Care
Pt was cleared for OT treatment per RN. Pt received supine in bed, agreeable to participate in the session. Pt reports 6/10 pain in L LE. Pt is on 2L 02 via n/c; O2 sats read 100% in supine. Pt A&Ox3, not oriented to the situation. Pt performed bed mobility utilizing log roll technique with Min A. Pt presents with good seated balance requiring SUP. Pt demo’s full ROM in bilateral UE’s and presents with ⅗ strength in L UE and ⅘ in R UE. Pt performed seated UE dressing with Min A to thread arms through sleeves. Pt desatted to 95% and educated on PLB techniques with good demo return and recovery. Pt performed seated LE dressing with Mod A to thread pants over feet. Pt performed sit to stand using FWW with Min A. Pt participated in a functional mobility task with CGA and demo’s fair dynamic standing balance. Pt performed standing h/g tasks at sink with setup and noted to have decreased activity tolerance as shown by need for rest break. Pt returned to EOB and educated on energy conservation techniques with good understanding. Pt O2 sats read 100% at end of session and pt returned to supine with needs in reach and bed alarm on. Outcomes discussed with RN.
School-Based
Kiddo reports feeling 7/10 tiredness at the start of the session. Kiddo participated in proprioceptive chair push up activity with good response. Kiddo appeared to be distracted during the OT session requiring redirection to task as evidenced by kiddo’s attempt to play with other items that were not part of the activity. Kiddo participated in a paragraph writing activity to address handwriting goals. Kiddo showed difficulty with letter sizing and writing lowercase letters 'y' and 'g'. Kiddo required moderate visual and verbal cueing throughout this activity. Kiddo did an excellent job cutting on a straight line and curved line demonstrating age appropriate scissor skills. Grip strength is within normal limits as determined by appropriately manipulating a squeeze glue bottle. Kiddo participated in a balance and bilateral coordination movement activity with no noted challenges to complete the session. Will continue to address letter sizing next session.
Outpatient Peds
Child’s mother reported an increase in ADHD medication and that he/she has been engaging in more conversation lately. Child came to the session today complaining of a headache. Therapist worked on zones activity, and handwriting. Child was able to identify his/her own zone with a visual support; however he/she had difficulty identifying appropriate zones of people in a story and required minimal verbal cueing. The child had good engagement throughout the story. Child presented with an inconsistent grasp pattern during handwriting as demonstrated by alternating between 3-4 fingers. Child had difficulty with letter formation and visual motor integration (copying letters). The child required max verbal cueing during this task and re-direction due to inability to follow directions. Continued practice with emotional regulation and handwriting tasks is recommended.
Early Intervention
Per caregiver report, client has had a rough week and shown more difficulty with transitions and increased tantrums. The client appeared to be more distressed throughout the session than usual as evidenced by an increase in stimming behaviors, tantrums and maximal redirection needed. The session focused on providing sensory input through proprioceptive and vestibular activities as well as role playing appropriate transitions. The client had a good response to the activities and was able to be redirected to task much easier following sensory input.
Outpatient/Hands Adult
Client reports, “I have difficulty buttoning my shirt because of the pain in my thumb.” Client reports 8/10 pain at IP joint. Treatment consisted of Paraffin x 15min, STM, adaptive strategies for dressing (i.e. buttoning with button hook), issued radial gutter splint with pt. education, IFC x 15min with ice x 5min. Pinch R UE 4 lbs. L UE 10lbs. Patient demonstrates an increased ability to type due to increased ROM in thumb, continued difficulty with buttoning due to impaired pinch strength. Continue with plan of care to increase ROM, decrease pain. Continue implementing adaptive strategies.
Home Health
Pt reported, “My shoulder feels better, I like the tape.” Pt and wife educated on how to apply KT tape to the shoulder. KT tape was applied to pt’s shoulder around anterior and post deltoid prior to ROM/strengthening exercises. Pt performed UE ROM activity in flex/ext as tolerated, with arm at shoulder width holding large ball, 10 reps x 3. Pt engaged in wrist strengthening activity on therapy ball to allow for deeper ROM (flex/ext/ulnar and radial deviation) 10 reps x 3 with 3lb weight. Pt participated in FMC activity and tendon glides with min tactile cues. Pt transitioned to cone stacking activity to improve ROM and shoulder mobility to improve independence in ADLs such as grooming and donning/doffing shirt. He performed cone activity 3x with mild discomfort w/ last 2 cones. Pt educated on dressing techniques to doff non-affected arm first then to thread long sleeve shirt off affected arm to prevent need to hyperextend L UE into a painful position. Pt participated in external rotation exercise with theraband 10 reps x 3. Pt educated on fall prevention and home modifications to avoid future falls. Continue with pt and caregiver education for fall prevention with use of grab bars and practicing safely entering and exiting shower safely with shower chair.
Wow! That seemed like a lot huh? Well, don’t worry, the more you practice writing these notes the easier it gets; I promise. Hopefully, this is helpful and if you have any questions drop them in the comments section below. Have a wonderful hump day!
XOXO,
OT Unfiltered