SOAP Note

S: “I am getting glasses...for seeing far away.” “I am 9.”

O: B performed a preparatory task of matching same letter clothes pins to a worksheet.

She used a pincer grasp when attaching the clothespins and matched all letters without
verbal prompts. She was independent in this task. B used a left-handed quadruped
grasp with a thumb hook while writing. She appropriately used her right hand to stabilize
the worksheet. B required moderate verbal prompts to write letters in the correct
spaces, not skip sentence lines and not copy the incorrect letters. However, she
independently completed the last word of the worksheet. B demonstrated proper letter
formation, only requiring verbal prompts for line length for the letters h,k,g, and d. B
wrote 0/9 letters on the line when writing her name. B required moderate verbal
assistance to sound out the words of the secret code. B was given the task of cutting
out images to glue to a haunted house worksheet. B cut within ¼” from the line and
glued the images independently.

A: B demonstrates age-appropriate fine motor control in handwriting and scissor

activities. B uses bilateral UE coordination to manipulate and control materials. She
recognizes the letters of the alphabet but has difficulty in near-point copying. She lacks
confidence in reading words out loud, which may be the effect of a number of factors
(i.e unfamiliarity, anxiety, deficits in reading). B required moderate verbal cues to follow
the coding worksheet in sequential order.

P: Skilled OT services are needed 60 minutes per month to address near-point copying,
far-point copying, and activity sequencing in order to help B access her general
education curriculum and increase classroom participation. B will receive additional
services from a speech-language pathologist and a resource teacher.

LTG: B will near-point copy a 5-7-word sentence with 85% accuracy in ⅔ data probes.

STG: B will near-point copy a 3-5-word sentence with 75% accuracy in ⅔ data probes.

LTG: B will write a 3-5 word sentence with 85% accuracy considering letter formation
and line adherence on 2/3 data probes.

STG: B will write a 3-5 word sentence with 75% accuracy considering line adherence on
2/3 data probes.