An occupational therapy SOAP note records a session in terms of function: the activities practiced, the help needed, and progress toward the client’s goals. Copy the free template, see two filled examples, and check how to record assist levels and cues.
Blank occupational therapy SOAP note template
FreeOCCUPATIONAL THERAPY SOAP NOTE Client: [Name] Date of birth: [Date] Date of session: [Date] Session: [Session number, and sessions planned] Diagnosis: [Medical diagnosis, and the occupational performance problem treated] Precautions: [Weight-bearing, orthosis schedule, fall risk, swallowing, cognition] Therapist: [Name, credentials] SUBJECTIVE Client report: [How daily activities have gone since the last session, in the client's words] Pain and fatigue: [Rating out of 10, and when it limits activity] Session goal: [What the client or caregiver wants to work on today] Home program and equipment: [Use of exercises, orthosis, or adaptive equipment at home] OBJECTIVE ADLs: [Task, assist level, type and number of cues, equipment used] IADLs: [Task, assist level, type and number of cues, equipment used] Transfers and functional mobility: [Surface, device, assist level] Upper limb and hand: [ROM in degrees, grip or pinch strength, coordination, edema, sensation] Cognition and safety: [Attention, sequencing, problem solving, safety awareness during tasks] Interventions: [Each skilled intervention with minutes, such as ADL training, therapeutic activity, neuromuscular re-education, orthosis fitting, or caregiver training] Client response: [Tolerance, change during the session, carryover from last time] ASSESSMENT Performance: [How today's performance compares with the last session and the baseline] Limiting factors: [Client factors or performance skills that limit occupation] Skilled need: [Why the session required an occupational therapist] Goal progress: [Each goal: met, progressing, or not yet met] PLAN Next session: [Tasks to grade up or down, and what to re-assess] Home program and equipment: [Exercises, activity changes, equipment ordered or issued] Caregiver training: [Who was trained, in what, and how they showed it back] Frequency: [Sessions per week, weeks remaining] Signed: [Clinician name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Outpatient hand therapy, session 6
61-year-old right-handed woman, 8 weeks after plate fixation of a right distal radius fracture. Her surgeon cleared light strengthening last week, and she has stopped wearing the wrist orthosis. Now buttons blouses and brushes her hair without help. Still can’t open jars, lift a full kettle, or turn the car key. Pain 2/10 at rest, 5/10 when gripping; stiff each morning. Home program 3 times a day. No numbness or tingling in the fingers, and no burning pain or color change in the hand.
Right wrist AROM: extension 45°, flexion 40°, supination 60°, pronation 75°. Left: extension 70°, flexion 75°, supination 85°, pronation 85°. Grip, dynamometer at the second handle position: right 9 kg (20 lb), left 26 kg (57 lb). Lateral pinch: right 4 kg (9 lb), left 7 kg (15 lb). Figure-of-eight hand measurement 1.2 cm (0.5 in) more than the left. Scar healed and mobile. Light touch intact. QuickDASH 45. Opened a medium jar independently with a jar opener and a non-slip mat. Interventions: moist heat to the forearm with skin check, 8 min; joint mobilization and active-assisted ROM into extension and supination, 12 min; grip and pinch strengthening with soft putty, 8 min; task practice with a jar opener, a built-up key holder, and pouring from a half-full kettle with both hands, 15 min; scar massage and edema education, 5 min. Total 48 min. Supination 66° after mobilization. Pain peaked at 4/10 with putty, settling to 2/10.
Recovering as expected 8 weeks after fixation. Grip is about a third of the left. Limited wrist extension, supination, and grip strength stop her opening jars, lifting a kettle, and turning the car key. Needs skilled grading of strengthening and mobility now that the fracture can take load, while watching for nerve irritation or signs of complex regional pain syndrome. Goals: button clothing independently, met; open jars with equipment, met; lift a full kettle with one hand, progressing; turn the car key independently, progressing.
Twice a week for 4 weeks. Next session: putty up to medium; add weight-bearing through the hand on a table and forearm rotation with a light hammer. Home program: wrist and forearm stretches 3 times a day, putty 2 × 10 twice a day, and scar massage. Recommended a jar opener and a key holder. Call the clinic for new swelling, color or temperature change, or burning pain in the hand.
Inpatient rehabilitation unit, day 9
74-year-old man, 2 weeks after a right middle cerebral artery stroke with left-sided weakness. Slept well. Says he wants “to get dressed on my own before I go home.” Left shoulder ache 2/10 when dressing. His wife will be his main help at home and plans to join a session this week.
Morning ADL session at the bedside and sink. Supine to sit: minimal assist to bring the left leg over. Upper body dressing, pullover shirt, seated: minimal assist to place the left arm in the sleeve, using the affected-arm-first technique, with 3 verbal cues. Lower body dressing, seated: moderate assist to get pants over the left foot and to steady him in standing; used a reacher. Grooming at the sink, seated: shaved the right side independently; 4 verbal cues to shave the left side. Toilet transfer with a grab bar: contact guard assist; cued twice to lock the wheelchair brakes. Left arm: shoulder flexion to 60°, gross grasp without release; one finger-width inferior subluxation at the shoulder, supported on a lap tray. Missed 2 items on the left of the sink until cued. Interventions: ADL retraining 35 min, neuromuscular re-education of the left arm within tasks 10 min, visual scanning to the left 10 min. Total 55 min. Fatigued after 40 minutes; one 3-minute rest.
Progressing. Upper body dressing has improved from moderate to minimal assist in 4 days, with fewer cues for the left sleeve: 3 today, 6 on day 5. Left inattention, poor standing balance, and limited left hand function are the main barriers to dressing and toileting. Not yet safe to transfer alone, as he forgets the brakes without cues. Needs skilled ADL retraining, graded cueing, and caregiver training before going home. Goals: upper body dressing with supervision, toilet transfer with supervision, and grooming with set-up only, all progressing.
OT twice a day while on the unit. Next session: lower body dressing seated, with a long-handled shoehorn and elastic laces; brake reminder cards on both armrests. Build scanning to the left into every task. His wife to join the dressing session on day 11 for caregiver training. At the team meeting, discuss a shower chair, a raised toilet seat, and a home visit before discharge.
The client’s view of daily life since the last session, and what they want from today.
Avoid: Recording only pain. In OT, what the client can and can’t do at home is the main report.
What the client did, how much help it took, and the measures behind it.
Avoid: “Min assist” without the task, the type of help, or the cues. Say what the help was for.
What the performance means: change since last time, what limits function, and why OT is still needed.
Avoid: Listing impairments without saying which task each one limits.
What the next session will grade up or down, and what continues at home.
Avoid: Leaving out caregiver training. If a family member helps at home, record what they learned and showed back.
“Mod A” tells the reader little on its own. Name the task, the part that needed help, and whether the help was physical, cues, or set-up.
Record the type and number of cues: verbal, visual, or tactile. Fewer cues for the same task is progress worth showing.
Grip strength and ROM belong in an OT note when they explain a task. Link each measure to the activity it limits.
Record safety awareness during tasks, such as brakes, sharp objects, or hot water, and what you did about it.
If someone helps at home, note what they were trained in and whether they showed it back.
Vero Scribe writes the OT SOAP note in your template from the session conversation, with the client’s consent, or from your dictation. You review the assist levels and goals, edit what you need, and copy it into your EMR.
An OT note centers on occupations: ADLs, IADLs, and the help needed to do them. Movement measures appear when they explain a task limitation. A PT note centers on movement, strength, gait, and the home exercise program.
Common levels are independent, modified independent, set-up, supervision, contact guard, minimal, moderate, maximal, and dependent. Minimal assist usually means the client does about three quarters of the task or more. Use your facility’s definitions, and record cues separately.
Describe what you analyzed, graded, adapted, or taught: a change to the task, the set-up, or the cues, and why. Then record the client’s response and what you’ll change next time.
Either, depending on your setting. Many occupational therapists say “client,” and hospitals often say “patient.” Follow your organization’s style.
Yes. Copy it, or download it as a Word or text file. No account needed.
The four-part note for most visits, with acute, musculoskeletal, and telehealth examples.
Occupational profile, environment, ADL and IADL performance, named assessments, goals, and plan.
Periodic review with assist levels then and now, goal status with evidence, and the updated plan.
A worked dressing-session note, with assistance and cueing examples.
The general format, step by step, with a checklist.
How Vero Scribe drafts SOAP notes for you to review and edit.
Notes, documents, and follow-up in one workspace.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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