SOAP Note

S-Miles presented to occupa onal therapy treatment session today with his mom and younger sister. Mom reports that
Miles was suspended from school following an incident regarding stealing and smearing feces in his school bathroom.
Mom reports that Miles also con nues to hoard/steal food at home. Miles has been responding well and has improved
behaviors at home following the implementa on of a posi ve reinforcement chart. Mom will follow up with behavioral
health services regarding behavioral concerns.
O-Miles completed dynamic balance ac vity on uneven surface with object retrieval to work on core strength and
postural control; required CGA to maintain balance and MIN VC to remain on uneven surface during object retrieval.
Miles completed object retrieval while weight bearing in quadruped posi on on uneven surface with CGA and MOD
verbal and visual cues to improve dynamic balance, postural control, and praxis skills. Miles completed sequencing
ac vity with MIN VC to improve execu ve func oning skills. Miles completed table-top visual-motor ac vity with 5/12
errors and required MIN VC to locate visual targets. Pa ent trialed shoe tying simula on with dual-color laces with
modeling and MAX verbal and visual cues. Miles mastered rst step of ac vity in ¾ trials and trialed following steps with
MAX A and frequent visual and verbal cues. Therapist presented printed materials from Zones of Regula on curriculum
as part of Miles’ HEP in order to improve state regula on and social par cipa on skills.
A-Miles shows progress in his postural control and motor planning as evidenced by his ability to complete bilateral
reaching while weight bearing in quadruped posi on on uneven surface. Miles con nues to demonstrate core weakness
and poor postural control as evidenced by his inability to maintain quadruped posi on and balance on uneven surfaces.
Miles also demonstrates improvements in comple ng func onal mul -step tasks as evidenced by retrieving and
assembling puzzle pieces. Miles also demonstrates progress towards tying his shoes IND by mastering rst step in ¾ trials
with modeling and cues from therapist. Max s ll lacks the FM and visual-motor skills to complete other steps of the task
IND.
P-Miles would bene t from con nued skilled occupa onal therapy services bi-weekly for 1 hour for 8 visits to address
balance and postural control, visual-motor integra on skills, trial more challenging sequencing and mul -step ac vi es,
trial all steps in shoe tying, and improve overall safety by improving body and environmental awareness.

LTG: Pa ent will e shoes IND in at least 75% of opportuni es per caregiver report.
STG 1: Pa ent will e his shoes with dual-colored laces, visual demonstra on, and minimal assistance in 3/4 sessions.
STG 2: Pa ent will e his shoes with regular laces and minimal assistance in ¾ sessions.
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