Documentation

Pediatrics
 Reports

Evaluation-
ReEvaluations

Progress Reports
Lecture outline Discharge Reports

SOAP Notes
Evaluation/Re-
Evaluations Initial Evaluations

● Occupational Profile
○ Background: Family,Medical, treatment
history, school, etc.
● Assessment
○ Standardized, parent report, norm vs
criterion referenced
● Observation
● Clinical Impressions
● Recommendations
○ Frequency of therapy, goals, etc.
Evaluation/Re- Re-Evaluations

Evaluations ● Reason for referral

○ Updated background info
● Update on current goals
○ Goal progress: met, unmet, revise, etc
● Developmental review
○ FM, GM, Adaptive, Social-Emotional, etc
● Assessment
○ Standardized, norm vs criterions, repeat
assessments preferred
● Recommendations
○ Continue therapy, discharge, change
frequency, new goals, etc.
Examples
Progress Reports
Format may be insurance dependant

May or may not include formal assessment

Goal progress

Recommendations

● Frequency, new goals, etc.

Examples
Discharge Reports
Format may be insurance dependant

May or may not include formal assessment

Goal progress

Recommendations

● Discharge with home carryover, discharge due to non-

compliance/participation, etc.
Pediatric Soap
Notes
Subjective
● Sets the stage for the story you are trying to tell
● Feedback from the child
○ May be based on parent report
○ May be based on child behaviors
● Short and concise
○ How does it contribute to the rest of the note?
Objective
● Detailed
● Objective measures/observations
● What data will be helpful for reader to know?
● Often largest portion of SOAP note
Assessment
● Clinical reasoning and expertise
● How do objective measurements compare to previous
sessions?
● Interpretations
○ Contributors to success/difficulty
Plan
● Specific is preferred over generic
● Recommendations
○ Frequency
○ Home-carryover plan
○ Plan for next session
○ Modification of treatment approach
Sample
T’Challa entered the session ready and willing to engage. Parent reported that he
had a good day at school. T’Challa was directed to engage in dressing simulation and
grooming sequencing tasks. He was able to independently manage 3 of 5 large buttons
on a button board, set-up required to complete the final two buttons. T’Challa was
able to independently sequence 2 of 5 steps of a grooming task with the assistance
of a visual schedule. Fine motor fatigue may have impacted his ability to complete
all buttons independently, however he demonstrated improved pincer grasp skills and
frustration tolerance for the task. T’Challa appeared to be distracted by other
children/noises in the gym, requiring moderate re-direction while engaged in the
grooming task. Challenges with attention to task secondary to sensory processing
challenges may have impacted his ability to engage in the grooming task with more
independence. Fine motor endurance activities should be the focus of the next
session. Working in a distraction free-space should also be considered. Parents are
recommended to incorporate a visual schedule at home along and support a
quiet/distraction free environment while engaging in grooming tasks.