Occupational Therapy (OT) SOAP Session/Progress Note

Subjective

• Client’s self-reported experiences, concerns, goals, or observations shared during session including function-related challenges, meaningful goals or priorities, emotional or psychological experiences, contextual changes.
• Duration, timing, location, quality, severity, and context of client self-reported experiences.
• Self-reported factors that worsen or alleviate concerns, including self-treatment attempts and effectiveness.
• How concerns have changed or evolved over time.
• Client-reported past occurrences of similar concerns, management approaches, and outcomes.
• Self-reported impact on daily activities, work, and life functioning.
• Relevant client-reported history including contributing factors, social history, family history.

Objective

• Occupational therapist’s observations of clinically relevant behaviours, performance in tasks, and measurable data during session including session focus, participation level, motor performance, cognitive functioning, sensory response, emotional state.
• Tools and assessments used including performance outcome measures.
• Mental state examination elements where applicable.
• Occupational therapist investigations with results completed during session.
• Summary of results of any psychometric assessments administered.

Assessment

• Clinical interpretation of client’s functioning in relation to occupational goals including client-demonstrated strengths and barriers, progress noted, barriers observed, current functioning in context.
• Statement about appropriateness and effectiveness of interventions.
• Clinical reasoning or justification for intervention approach.
• Any change in diagnosis or prognosis, including differential diagnosis considerations.

Plan

• Next steps, goals and recommendations for client including plan for next session, ongoing focus areas, assessments planned, changes in treatment.
• Recommendations and referrals, goal review and updates.
• Time, date and location of next session.