Occupational Therapy SOAP Note Template
This Occupational Therapy SOAP Note Template is designed to streamline clinical documentation of functional issues, therapy sessions, and progress in pediatric or adult clients. It provides structured guidance through Subjective, Objective, Assessment, and Plan sections, ensuring clarity and compliance with professional standards. Used with Heidi, the AI medical scribe for all clinicians, this template helps occupational therapists easily:
- Capture relevant client-reported concerns such as fine motor delays, functional limitations in school or daily living tasks, symptom progression, and contextual updates from caregivers or educators.
- Record measurable observations from the therapy session, including physical or cognitive assessments, motor skill evaluations, and behavioral responses to therapeutic activities.
- Outline a forward-looking plan that may include therapy frequency, home exercise programs, patient or caregiver education, follow-up actions, and referrals where appropriate.
What is an Occupational Therapy SOAP Note Template?
An Occupational Therapy SOAP Note Template is a standardized format used by occupational therapists to document patient encounters and treatment progress. The SOAP format (Subjective, Objective, Assessment, Plan) helps ensure that clinical notes are clear, consistent, and compliant with medical and legal standards.
In this article, we’ll talk about the importance of Occupational Therapy SOAP Note templates, provide you with practical tips on how to write clear and compliant occupational therapy SOAP notes, explain how notes are written for different cases, and most importantly, share ready-to-use and AI-enabled occupational therapy SOAP note templates for use in your daily practice.
Why is an Occupational Therapy SOAP Note Template Essential?
An Occupational Therapy SOAP Note Template is essential for organizing clinical information into Subjective, Objective, Assessment, and Plan sections.
The clear segmentation of data makes it easier for therapists to track progress over time, communicate more effectively with other healthcare providers, support insurance billing and reimbursement by adhering to documentation standards, and reduce the risk of errors and missed information through consistent formatting.
How to Write Clear and Compliant Occupational Therapy SOAP Notes
With the globalization of healthcare, the importance of high-quality clinical documentation cannot be overstated. Aside from supporting continuity of care, well-written documentation is also meant to ensure accurate reimbursement, protecting both the client and clinician from the legal and financial repercussions of non-compliance.
Let’s talk about how to write each component of occupational therapy SOAP notes, along with the common mistakes to avoid in order to ensure compliance:
(S) Subjective - Capturing the Client’s Voice and Context
In the first section, which records the “Subjective” data from the therapy session, your notes should focus on recording your client’s experiences, concerns, and symptom description in their own words. This, however, doesn’t necessarily mean you should simply write down what they say in verbatim. It’s important to use your best judgment as you quote and paraphrase with the intention of documenting impartially and concisely.
For example, if the client shares something like this: “I get really frustrated when I try to button my shirt. My fingers feel clumsy ,and I usually give up halfway. It’s been like this since my surgery, and it’s not getting any better. I feel useless sometimes.”
Your notes under the “Subjective” section could look like this: The client expressed ongoing frustration with fine motor tasks, specifically buttoning their shirt. She states her fingers “feel clumsy” and that she “often gives up halfway.” She also reported that these challenges began post-surgery and have not improved, contributing to feelings of discouragement and decreased independence.
(O) Objective - Recording Measurable Observations
Unlike the first section, the “Objective” section is meant to outline factual and measurable data, including the therapist’s professional observation, established performance metrics, session activities, and standardized assessment scores.
Remember to only record purely fact-based information in this section, leaving out subjective interpretations and/or assumptions. Typically, the tests whose results are recorded in this section are done consistently across sessions to accurately track progress.
Sample note:
- Completed upper limb coordination exercises, including reaching, grasping, and manipulation drills for 25 minutes.
- Noted improvement in motor control with decreased tremors (observed 2-3 episodes per task vs. 6-7 last session)
- Range of motion in the right shoulder measured at 110° flexion and 80° abduction.
(A) Assessment - Synthesizing Clinical Insights
The assessment section is where the therapist uses the documented subjective and objective data to outline the client’s progress or setbacks. Additionally, justifications for the continuation of the treatment plan, potential reasons for plan modification, as well as explanations for the client’s progress plateaus are outlined here.
Sample note:
- Client continues to demonstrate fine motor deficits impacting daily functional tasks such as handwriting and buttoning clothing.
- Based on observed performance and caregiver feedback, symptoms are consistent with Developmental Coordination Disorder.
- Mild progress noted in grip strength and task initiation, but still requires moderate verbal cues and physical assistance for more complex tasks.
- Client remains motivated and responsive to interventions, indicating good potential for improvement with continued therapy and home practice.
(P) Plan - Defining Next Care Steps
In the final section, outline immediate and future actions to be taken for the client. This includes session frequency, treatment focus, home programs, follow-ups, and referrals if applicable. As much as possible, specify measurable goals and clear timelines in this section to support billing justification as well as care planning.
Sample note:
- Continue sessions twice weekly for 45 minutes each, focusing on fine motor coordination and hand strengthening.
- Introduce adaptive tools like pencil grips and button hooks in upcoming sessions to support independence in self-care tasks.
- Implement a home exercise program targeting grip strength and bilateral coordination to be practiced 10-15 minutes daily with caregiver supervision.
- Reassess fine motor skills in four weeks using BOT-2.
- No referrals or additional assessments required at this time.
Even with best practices in place, many occupational therapists may still struggle to document thoroughly and efficiently, especially when managing full caseloads. This is why some practices have turned to AI-powered medical scribes to streamline documentation and reclaim valuable hours in their day.
Accelerate Abilities, a therapist-led practice, was growing fast. With referral volumes climbing and therapists scattered across multiple states, the paperwork kept on compounding week after week. “I was spending approximately two hours a day on completing notes and communicating these to client families,” shared Peter Pazios, one of the co-founders. “When I was out and about in the community, that’s when I would take a lot of report-writing notes home, and I’d have to do that in my own time.”
Thankfully, Peter eventually discovered Heidi. After trialing it against other similar tools, Heidi immediately emerged as the clear choice, and they quickly rolled it out to their other locations. Accelerate Abilities’ therapists now save up to 2 hours per day on documentation, finishing all of their notes during regular work hours. “The team has said they don’t know how they did their day-to-day without Heidi. It’s been a game changer,” Peter shared.
Occupational Therapy SOAP Notes for Different Cases
While the SOAP format generally remains consistent across notes, clinical context and specific client demographics may influence how notes are actually written. By tailoring their documentation based on the goals of care, therapists can improve communication with different stakeholders such as parents, caregivers, or other clinicians, enhance overall care planning, and ensure compliance.
Below, we’ll provide practical tips to help you write SOAP notes for three high-demand contexts:
Pediatric Occupational Therapy SOAP Notes
Subjective: Include observations from parents, caregivers, or teachers, in addition to the child’s own verbal input. You should also highlight behavioral cues and the child’s developmental history in this opening section.
Objective: Focus on documenting play-based activities, developmental milestones, sensory processing, and motor skill assessments. It’s best to use standardized pediatric assessment tools such as the Peabody Developmental Motor Scale 2nd Edition (PDMS-2), and the Bruininks-Oseretsky Test of Motor Proficiency 2nd Edition (BOT-2) to gather objective, measurable, and actionable data.
Assessment: Document the child’s progress toward age-appropriate goals such as handwriting and dressing skills, highlighting any environmental or behavioral influences affecting their performance.
Plan: Where possible, include collaboration with family or school staff, home activities, and short-term goals that align with set developmental objectives.
Geriatric Occupational Therapy SOAP Notes
Subjective: Document client-reported difficulties with Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs), pain, fatigue, or cognitive changes. Where relevant, you should also include caregiver reports and observations.
Objective: Focus on documenting functional mobility, fall risk, strength, Range of Motion (ROM) assessments, and the client’s use of adaptive equipment where applicable.
Assessment: Based on the subjective and objective documentation, connect your physical and cognitive findings to the client’s safety, independence, and quality of life. Additionally, you should identify and highlight risks such as isolation, depression, or progressive decline.
Plan: Outline strategies for maintaining independence, reducing fall risk, and supporting aging-in-place. If the client has caregivers, note any instructions you’ve provided to them, and also document referrals to other healthcare providers where applicable.
Neurological Occupational Therapy SOAP Notes
Subjective: Capture symptoms like fatigue, visual disturbances, or cognitive challenges as shared by the client in their own words. You should also note any emotional responses including fear and frustration, among others.
Objective: Highlight motor function assessments for strength, coordination, and balance, and include information on the client’s functional performance, especially in the context of ADLs and IADLs. Where applicable, this is where you also include cognitive and perceptual evaluations for attention, memory, problem-solving, and visual scanning.
Assessment: Document impairments in relation to neuroplasticity, rehab potential, and the client’s functional goals. If the client’s progress has plateaued, note the need for reevaluation, the possibility of modifying goals, or transitioning to maintenance strategies instead of restorative.
Plan: Outline targeted interventions, including task-specific training such as brushing one’s teeth or using utensils to retrain motor control and function. Also note the potential introduction of tools or modifications that will help the client compensate for deficits and maintain their independence, especially in cases where full function cannot be restored.
Occupational Therapy SOAP Note Template Example
Traditional documentation methods are time-consuming and prone to inconsistencies. Thankfully, today’s therapists now have access to Heidi, our AI-powered medical scribe designed to streamline the completion of occupational therapy SOAP notes without sacrificing quality, compliance, or clinical detail.
Easily Complete Occupational Therapy SOAP Note Templates with Heidi
Heidi is the AI medical scribe designed to help therapists complete their occupational therapy SOAP notes in real time. With the permission of your client or their guardian, simply hit record and let Heidi work as you go. Here’s how Heidi helps you complete your case notes:
- Transcribe – Open Heidi on your computer or mobile device and press Start transcribing so Heidi can capture your therapy session in the background. For information that you don’t want to verbalize, you can type it under context notes to be considered later.
- Customize – After the session, simply select your preferred occupational therapy SOAP note template and watch as Heidi perfectly transcribes the details of your session and context notes in the appropriate fields and format!
- Transform – Once your completed occupational therapy SOAP note has been generated, you can even ask Heidi to generate additional documentation, including home health notes as needed.
Heidi complies with jurisdiction-specific regulations, ensuring data localization for customers in Australia, Canada, the United States, the United Kingdom, and beyond. Read more about our patient safety and data security compliance here.
Free Occupational Therapy SOAP Note Templates
Daily Occupational Therapy Notes Template
This occupational therapy SOAP note template is designed to help therapists document client assessments and recommendations. It includes sections for initial consultations, client needs, specific recommendations for skill development, and independent living.
Initial Occupational Therapy Note Template
This initial occupational therapy note template is designed to help occupational therapists assess and document the needs of individuals with disabilities. It covers a wide range of areas, including medical history, medication management, social supports, education, cognition, communication, mobility, and daily living activities.
Occupational Therapy Assessment Template
This occupational therapy assessment form is a comprehensive template designed to help therapists evaluate a client’s functional abilities and needs. It captures detailed client information, including medical history, living situation, and support systems.
FAQs About Occupational Therapy SOAP Notes
What are some key considerations when writing occupational therapy SOAP notes?
Consider how your notes might be interpreted by third parties who weren’t present during your sessions, including insurance reviewers or fellow healthcare providers (in case of referrals). Make sure that you write with enough clarity and context that your documentation can stand alone and has no chance of being misinterpreted.
What is the difference between physiotherapy and occupational therapy SOAP notes?
While both follow the SOAP format, occupational therapy notes focus on improving a client’s ability to perform daily activities and functional tasks, whereas physiotherapy notes emphasize restoring physical movement, strength, and mobility (think a professional athlete attempting to make a comeback after a major injury). For this reason, the goals, interventions, and outcomes recorded can vary widely between the two types of therapy SOAP notes.
How can I make sure my OT SOAP notes are audit-ready?
Audit-ready OT SOAP notes are clear, complete, objective, and compliant with both clinical and legal documentation standards. Heidi, the AI medical scribe for all clinicians, helps you achieve this by structuring your notes in real time and flagging missing information to guarantee completeness and consistency for each note you generate. Learn more about how Heidi works.