How to Write an OT SOAP Note - Simply Special Ed

Documentation, like a SOAP note, can be one of the least favorite parts of the job for many occupational therapy practitioners (OTs). I love to write, but documentation is hard for me! In the schools, there is A LOT of paperwork! But these notes don’t have to be hard! They don’t need to take up copious amounts of time. We definitely want to spend most of our time working directly with our clients. However, there are logistical reasons that documentation is importnat. You can even think about this as “if it’s not documented, it didn’t happen”.

simple data sheets for special education; documentation and note resources from simply special ed that could be used in addition to writing a SOAP note

What is a SOAP Note?

The four sections of a SOAP note [subjective, objective, assessment, plan] help us briefly communicate what happened, what we observed and why, as well as what the plan is going to be moving forward. For the purpose of this blog, I will focus on school-based note writing. Just remember, you can use the SOAP note format in any setting. Hopefully the below breakdown makes your documentation a little bit easier!

S = Subjective

This section of the note likely will come directly from the student. Did they say something about how they are doing or feeling? What did the student ask you? Did their teacher or support staff member report something when you picked them up? In this section of the SOAP note, you are giving a subjective report of the student’s current status.

student working on a handwriting sheet with the letter "s" in cursive and manuscript with an adult helping similarly to the handwriting discussed in the SOAP note

Johnny left his third grade classroom for his OT session saying “I just can’t do this!” in reference to the writing assignment that he was working on in class. He brought the paper with him to the session, and reported that his hand hurt from “so much writing today”.

O = Objective

While the “S” section doesn’t involve facts, per se, but rather a client’s report, the “O” section reports objective facts. What did you do during the session? Remember to keep this objective [as the name implies]. You don’t need to include your interpretation or analysis of what happened or how the client performed in this section. Just state the facts! Did you collect data during this session? You can report that in this part of the SOAP note! You can indicate why specific interventions were chosen or what skills were elicited in the “O” section as well.

OT student pulling beads out of yellow theraputty similar to what was discussed in the below SOAP note

The student participated in a 30 minute OT session focused on visual perceptual skills and fine motor strength to support handwriting legibility. The student selected between two visual perceptual tasks to start the session. He independently located 10 of the 15 hidden items in the chosen figure ground hidden picture activity, and found the remaining 5 with one visual cue per item to narrow the visual field in which he was scanning. The student completed hand strengthening exercises with soft (yellow) theraputty requiring a therapist demonstration/model to support motor planning. The client was able to complete the worksheet he brought from class with 73% accuracy in letter formation and 83% accurate in baseline adherence when provided with adapted 3/4 inch three lined paper with a raised baseline.

A = Assessment

This is the part of the SOAP note in which you get to show off all of your OT knowledge! After you’ve stated the facts about what happened during your session in the “O” section, you can get report your interpretation [or Assessment] of what happened here! Think of this as the “so what?” section of the note. You have probably worked hard on setting goals for your client. Relate their current performance back to their goals in this section. Are they progressing? How did you see that progress, and what does that mean for their function?

OT student writing on adapted highlighted paper with a raised baseline using visual aides and a finger spacer for organization of writing on the page as was discussed in the assessment portion of the SOAP note

The student’s ability to perform the writing tasks in the therapy classroom with decreased number of adult prompts indicates good potential for independent handwriting performance once carryover of adapted handwriting strategies improves. The student shows improved visual perceptual skills as seen by his ability to maintain appropriate letter sizing on structured highlighted paper. His accuracy improved 10% since last session to 83% as he nears the desired mastery level of 85% accuracy in his current IEP goal. The student could benefit from continued OT intervention and direct instruction addressing motor planning required for accurate letter formations as he currently writes with less than 75% accuracy within this legibility component.

P = Plan

Based on what you noted above, what do you plan to do? Are you going to continue to work with the student on the same skill areas and goals? Are there any changes to the plan? This portion of the note can be relatively short!

Simple Writing Letter Book visual for lowercase "a" letter formation practice as was suggested in the plan of the SOAP note

It is recommended the student continue with 120 minutes per month of direct occupational therapy intervention to address visual perceptual skills, hand strength/endurance, adapted handwriting strategies and classroom carryover. Intervention is required to continue to make progress on handwriting legibility IEP goal. Rather than four pull out sessions per month, it is recommended that sessions be held in the classroom setting (push in delivery model) for 60 minutes per month, and the remaining 60 minutes per month occur in the OT classroom to improve carryover.

Do you need handwriting resources?

Check out the following Simply Special Ed resources: