OCCUPATIONAL THERAPY SOAP NOTE — ADULT SESSION
Client / encounter identifier:
Service date / session start and end / entry time:
Practitioner name, role and credentials:
Setting / people present / consent or communication support:
Relevant precautions and current plan-of-care reference:
Functional goal addressed / target date:

S — SUBJECTIVE
Client's account of the activity since the previous session:
Client priority or preference today:
Symptoms or fatigue reported / scale and timing if used:
Caregiver or other report, with source and date:

O — OBJECTIVE: TASK, INTERVENTION AND RESPONSE
Task and setting / materials or equipment / starting conditions:
Baseline or previous comparison, with date and source:
What the practitioner did or changed and why:
Performance before and after that change:
Physical assistance: who helped, with which part, and how:
Set-up / supervision / type, number and timing of cues:
Result: amount completed / time / errors / breaks / response:
Teaching provided and what the client or caregiver demonstrated:
Tasks or measures not assessed / reason:
Service-time record: actual interventions and applicable minutes;
timed-code minutes, total treatment time and excluded time where required:

A — ASSESSMENT
What today's findings mean for the functional goal:
Comparison with the dated baseline under comparable conditions:
Effect of equipment, cues, setting or other changed conditions:
Goal status and evidence / remaining limitation:
Clinical reasoning for the skilled work or revised approach:
What is still unknown about performance outside this session:

P — PLAN
Next agreed task or reassessment / responsible practitioner / date:
Current plan-of-care frequency or changes approved by the responsible clinician:
Home activity or equipment arrangements actually agreed:
Pending actions: owner, checkpoint and status:
Client preferences and communication completed:

FINAL CHECK
Narrative agrees with goal tracker, assistance fields and time record:
Corrections preserve the earlier entry and identify author, date and reason:
Authentication / supervision or co-signature required in this setting: