Tips for Effective Occupational Therapy Documentation:

Using the SOAP Note Method

Presenter: Crystal A. Gateley, Ph.D., OTR/L

CAOT Lunch & Learn - June 30, 2015

Writing Functional Problem Statements

 Area of occupation affected

 Contributing factor(s)

__________________________ results in _____________________________________.

Contributing factor what occupational deficit

Examples:

 Lack of stress management skills results in client difficulty sustaining employment more than 2
weeks.
 Pain level of 5/10 with finger flexion in left hand leads to inability of grasping a writing
instrument for more than 3 minutes.
 Decreased B UE AROM due to spinal cord infection results in need for maximal assistance to
complete dressing tasks.
 Oral tactile defensiveness results in limited variety of food intake.
 Asymmetrical positioning in wheelchair affects child’s ability to feed self independently.
 Decreased memory affects resident’s ability to safely locate and access an exit to building in
emergency situations.
 Sensory-seeking behaviors and decreased attention result in inability to complete classroom
assignments in a timely manner.
 Inattention to personal hygiene limits client’s ability to find employment.
 Decreased balance and endurance limit client’s ability to carry bucket of feed to farm animals.
 Unfamiliarity with post-surgical precautions and adaptive equipment limit client’s safety and
independence with dressing.
 Preoccupation with aligning objects limits child’s pretend play interactions with preschool
classmates.
 Impaired problem-solving skills limit client’s ability to utilize public transportation to attend
social events.
COAST Goals
 C – Client
 O – Occupation
 A – Assistance Level
 S – Specific Conditions
 T – Timeline

The “A” and the “S” together makes your goal measurable and allows you to show your client’s
progress. In some cases, it is acceptable to omit either the “A” or the “S,” but never both.

The COAST elements may be rearranged, but you should always keep the “C” and “O” together.

Examples:

 Client will perform a 3-step cooking process, with 2 or fewer verbal cues for sequencing and
safety, from wheelchair level in rehab kitchen within 1 week.
 Patient will complete self-catheterization using adaptive equipment with minimal verbal cues
for technique with 2 sessions.
 Patient will complete bathing tasks seated on tub bench using long-handled sponge with SBA
within 3 days.
 Sophia will don coat using over-the-head method with modified independence within 1 month.
 Within 3 treatment sessions, Mr. S will complete toileting using raised toilet seat with minimal
assistance for balance during clothing adjustment.
 Client will demonstrate ability to change infant’s diaper using adaptive one-handed techniques
with 2 or fewer verbal cues within 1 week.
 Child will feed self at least 50% of meal using adaptive spoon with moderate assistance within 3
weeks.
 Client will transfer 10 laundry items from washer to dryer with 2 or fewer verbal cues to adhere
to postsurgical back precautions by 7/3/15.
 Resident will identify and navigate safe route from bedroom to exit of facility independently
within 2 weeks.
 Christopher will navigate public bus system from home to doctor’s office with supervision during
next treatment session.
 Using visual checklist as a memory aid, client will remember to lock doors before bedtime on 5
consecutive nights by July 31, 2015.
 Olivia will take turns on playground equipment without adult intervention 3 of 4 consecutive
days by end of October.
 Emma will stack 6 or more blocks using right hand to stabilize tower without verbal cueing
within 1 month.
 By end of school year, Liam will tolerate unexpected touch from peers during circle time without
demonstrating aggressive behaviors 80% of time per teacher report.
 Writing SOAP Notes

 S – Subjective
 O – Objective
 A – Assessment
 P – Plan

Examples:

S: Client says she has difficulty moving her R UE, although she does not understand why it will not
move. She reports, “It doesn’t really hurt. It’s just tight.”

O: Client participated in 45-minute occupational therapy session in hospital room and

rehabilitation gym for UE activities to increase R UE AROM and strength, activity tolerance, and
dynamic standing balance in order to improve safety and independence with ADL tasks.
ADLs: In room, client received skilled instruction in safety techniques and adaptive equipment
use for toileting. Client needs B grab bars in bathroom for safe sit to stand transition during
toileting. Client attempted to stand up by pulling up on walker. Client was educated on safety
issues and use of B grab bars; she verbalized understanding of recommendations.
Performance Skills: Client required CGA for balance during sit to/from stand. In order to address
activity tolerance, dynamic standing balance, and R shoulder AROM, client moved canned goods
from counter to cupboard for 5 minutes with CGA before needing a 2-minute seated rest break.
Next, she participated in activities to increase dynamic standing balance by pouring liquid from a
pitcher while standing with CGA for balance. Following a 1-minute rest break, client continued
activities to increase dynamic standing balance and safety by retrieving objects from floor using
reacher while ambulating with wheeled walker and CGA.
Client Factors: R shoulder abduction AROM = 90 degree. R shoulder abduction PROM WFL.

A: Impulsivity and decreased dynamic standing balance pose safety concerns during sit to stand
transfers for toileting. Decreased R UE shoulder AROM, decreased activity tolerance, and
decreased dynamic standing balance all interfere with ability to complete ADL and IADL tasks
safely and independently. Verbalization of understanding safety instructions demonstrates
progress. Client’s motivation and supportive family indicate good potential to return home at
discharge. Client would benefit from R UE AROM and strengthening exercises along with
continued skilled instruction in safety issues and energy conservation techniques.

P: Continue to treat client 5X/week for 1 week for skilled instruction in safe toileting transfers and
IADLs. Plan to address dynamic standing balance and to provide skilled instruction in energy
conservation techniques. Home program for AROM and strengthening exercises for R shoulder
will be introduced at next session.
S: Parent reports that infant is steadily gaining weight and will probably be able to discontinue
oxygen within the next few weeks.

O: Infant participated in a 30-minute occupational therapy session in home to assess visual skills
and to increase mobility skills related to play (head righting, rolling supine to side lying, and
prone-on-elbows). Infant oriented to black and white laminated design by turning head. Infant
demonstrated visual tracking in horizontal plane 20 degrees past midline. Infant unable to roll,
right head, or push up in prone independently, but with facilitation of weight shift and proximal
stability, infant could perform each activity and hold for about 20 seconds. Infant became
fatigued and fussy after 20 minutes of treatment, with four 2-minute rest breaks.

A: Decreased postural control and need for facilitation of weight shift limits infant’s ability to
perform early mobility skills needed for play. Limited mobility combined with her tolerance for
less than 20 minutes of activity and the need for frequent rest breaks limit her ability to explore
her environment and reach developmental milestones in play and fine motor skills at a typical
age. Ability to perform transitional movements with facilitation, orientation to black and white
designs, and ability to track in horizontal plane show good potential for future developmental
gains. Infant would benefit from continued occupational therapy services to stimulate
developmental skills and from parent education in a home program.

P: Infant will be seen in home twice weekly for 3 months for activities that encourage postural
control needed for play and developmental exploration. Sessions to include parent education
targeted at facilitating developmental milestones during play and exploratory activities. Plan to
formally reassess infant’s developmental level in 3 months.
S: Client reports, “Last time they told me I had schizophrenia. Now they say I’m bipolar.” Client
reports she understands the purpose of social skills group and expressed a desire to attend all
group sessions, saying they are “fun.”

O: Client participated in 60-minute social skills group focusing on friendship. Client appeared
unkempt, with her hair uncombed and shirt wrinkled. Client engaged in conversation with the
other clients and facilitator. Client interrupted others on 5 occasions. Client spontaneously
verbalized her experiences with past friendships and her ideas of useful ways to make new
friends, but had to be redirected to the topic twice during discussion.

A: Client’s unkempt appearance, interrupting behaviors, and need for redirection to topic of
conversation interfere with her ability to engage in social participation with peers. Her
expressed interest in group activities and willingness to engage in conversation and share ideas
show good potential to develop relationships and to express herself verbally in place of acting
out. Client would benefit from participating in groups where conversational skills are stressed,
from further facilitation of attention to social cues, and from instruction in ADL activities
stressing hygiene and appearance.

P: Client to continue social skills group 3 times per week for 1 week to improve conversational
skills. Client will also receive daily feedback on her attention to appearance and social cues.
S: Client reported that she bent to floor to pick up her makeup case this morning. She stated, “I
just have a hard time remembering not to bend down.” Daughter reports she will provide
increased supervision to help client remember to follow hip precautions.

O: Client participated in 45-minute session in her home with daughter present for skilled
instruction in maintaining post-surgical hip precautions during household management tasks.
Client ambulated to dining room using wheeled walker with SBA for balance. Client retrieved
snack from refrigerator and utensils from drawer with SBA for safety. Client required 4 verbal
cues to remember hip precautions for stand to sit and when turning with walker. Following
skilled instruction, client was able to retrieve items from floor using a reacher. Education
provided to client and daughter on hip precautions and safety during basic and instrumental
ADL tasks. Client and daughter both voiced understanding.

A: Client’s inability to remember hip precautions without verbal cues limits ability to safely perform
household management tasks. Supportive daughter and ability to use adaptive equipment
properly after instruction indicate good potential for reaching goals. Client would benefit from
further skilled instruction in maintaining hip precautions during ADL tasks, sit to/from stand, and
household management tasks.

P: Continue occupational therapy twice weekly for 2 weeks to work on incorporating hip
precautions into ADL and IADL tasks. Instruction of reacher will be continued, and written
reminders (text and pictures) will be posted in prominent locations including bathroom,
bedroom, and kitchen.
 A Quick Checklist for Evaluating Your Note

Use the following summary chart as a quick reference guide to be sure that your note contains all the
essential elements.

S:
  Use something significant that the client and/or caregiver said about his or her treatment
or condition.
O:
  Begin with a statement about the length, setting and purpose of the treatment session,
using wording that indicates active participation by the client.
  Follow the opening statement with a summary of what you have observed, either
chronologically or using categories.
 Be professional, concise, and specific.
  Focus on occupation.

 Focus on the client’s response to the treatment provided, rather than on what the

therapist did.
 Write from the client’s point of view leaving yourself out.

 Be specific about assist levels.

  Avoid making a list of actions and assist levels.
  Deemphasize the treatment media.
  Make certain that it is clear that you were not just a passive observer in the session.
  Avoid judging the client.
  Use only standard abbreviations.
A:
  Go sentence by sentence through the information presented in the “S” and the “O”, asking
yourself what it means for the client’s ability to engage in meaningful occupation. Note
what problems, progress, and potential for rehabilitation you see.
 Remember the formula that puts the contributing factor as the subject of your sentence:
 Contributing Factor > Impact > Ability to Engage in Occupation
 End the “A” with “Client would benefit from…” justifying continued skilled OT and setting
 up the plan.
 Be sure that the time lines and activities you are putting in your plan match the skilled OT
 you say your client needs.
P:
  Specify the frequency and duration of future OT sessions. (Ex: 2x/week for 4 weeks)
  Describe the purpose of future OT sessions.
  Include a brief description of the intervention strategies that will address the client’s goals.