SOAP in Brief

Question 1

S section

Answer 1

Subjective
• Anything significant that client says
• What primary caregivers say
• Non-verbal communication
• Client’s perceptions of tx, goals, progress, condition, etc.
• Report of pain
• Important info relevant to tx (Make sure it’s not better in O section!)

Question 2

O section

Answer 2

Objective
• CLIENT FIRST language
• Your observations summarized for session
• **Start with FORMULA:
“Client participated in___-min session in ___ (setting) to work on ____ (purpose).”
• Organize CHRONOLOGICAL or CATEGORICAL
• De-emphasize tx media
• Describe assist levels
• Use skilled language
• Concise; info to help next practitioner

Question 3

A section

Answer 3

Assessment
• Your professional input on meaning of what you observed
• PROBLEMS, PROGRESS, and POTENTIAL
• Aspects of OT domain that are not WFL
• NO NEW INFO
• **Use FORMULA:
“Limiting Factor > Functional Impact > Ability to Engage in Occupation”
• **End section with: “Client would benefit from…” statement!

Question 4

P section

Answer 4

Plan
• What follow-up is required; plan for next session
• What is to be addressed in near future
• Recommendations for client/family/AE?
• **Must follow intervention plan!
**Start section with: “Continue OT for …” type statement.
• Will inform reader of priorities
• **Cover what hasn’t been covered in last sentence of A (…benefit from…)
• **END WITH A COAST GOAL!

Question 5

COAST Goals

Answer 5

(Used at end of SOAP-PLAN section!)
C=Client
O=Occupation
A=Assist Level
S=Specific Condition
T=Timeline (*Does not have to be in this order!)

• Client will perform…
• What occupation?
• With what assist level?
• Under what condition/AE/position/etc.
• By when?

“After skilled instruction, parent will demonstrate proper technique to position child for feeding by end of 2nd tx session.”

“In order to begin writing her name, student will demo ability to hold pencil with static tripod grasp by 6/1/20.”

“Client will complete setting table with SBA using rolling walker and walker tray in 1 wk.”

Question 6

Assessment Formula

Answer 6

Limiting Factor > Functional Impact > Ability to Engage in Occupation

Ex: L sided weakness interferes with client’s standing balance/safety in the tub.

Question 7

Objective Formula

Answer 7

Client participated in___-min session in ___ (setting) to work on ____ (purpose).

Ex: Resident participated in 45-min session bedside for instruction in compensatory dressing techniques.