OT SOAP note example
Daily living · OT session
Subjective
The client’s priority
“I want to get ready for work by myself.” Shirt buttons are the hardest part of J. Morgan’s morning routine.
Objective
The activity & what happened
The OT demonstrated button-hook use and adjusted the fabric setup. J. Morgan fastened three buttons with supervision and one verbal cue for fabric positioning.
Assessment
What changed
Less physical help was needed than at the last visit. Fabric positioning remains the main step needing a cue.
Plan
The agreed next step
Revisit the morning routine next session. Note which steps feel easier and where support is still needed.



