OCCUPATIONAL 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]