SOAP Notes: ASSESSMENT

Question 1

What is in the Assessment section of SOAP?

Answer 1

This is the heart of your note! Contains your personal judgment, possibly including:
• Appraisal of progress
• Functional limitations
• Pertinent issues
• Expected gains from rehab
• Inconsistencies/explanations
• Emotional components
• Document principles/strategies used
• **Problems, progress, potential (3 Ps)**

Question 2

What are the 3 Ps?

Answer 2

In the Assessment section of SOAP note, use the 3 Ps to guide what to include:

1) PROBLEMS: what’s the issue addressed?
2) PROGRESS: made during tx, of any scope
3) POTENTIAL: optional; what client may gain by continuing tx

Question 3

PROBLEMS in Assessment note

Answer 3

May include:
• Safety risks (ie: balance)
• Inconsistences (ie: client says he’s motivated but has missed sessions)
• Factors not WFL that OT can help (ie: pain that limits ability, ROM deficits, etc.)

Question 4

PROGRESS in Assessment note

Answer 4

Provide verification that tx is skilled and effective (how OT is benefitting pt.)
• State when previous goals are met/changed
• State reasons for lack of progress (meds changed? Had flu?)
• State steps toward goals (ie: less verbal cues needed)
• State when a tx is effective (ie: weighted utensils decrease tremor; increased level of safety awareness in tub transfer; 10˚ increase in AROM allows pt. to don shirt)

Question 5

POTENTIAL in Assessment note

Answer 5

State how pt.’s progress shows potential for successful rehab, etc.
• “Pt.’s ability to recall hip precautions shows good potential to follow them after D/C.”
• “Child’s progress from 50-75% accuracy of copying shapes indicates good potential to meet goals of IEP.”
• *Never document POOR potential, as it negates need for OT!

Question 6

Ending Assessment note

Answer 6

Should end A with “Client would benefit from continued OT to…”
• End with justification of continued treatment that requires OTP skill!

Question 7

FORMULA to use in Assessment note:

Answer 7

“UNDERLYING FACTOR > FUNCTIONAL IMPACT > ABILITY TO ENGAGE IN OCCUPATION”

Ex:
• Deficits in UB strength limit Pt.’s ability to complete ADLs.
• Decreased safety awareness limits Pt.’s ability to cook (I).
• Lack of forearm supination interferes with child’s ability to perform developmental play tasks.

Question 8

Skilled services for Assessment note

Answer 8

State skilled OT interventions required for client’s continuation in OT tx. Use skilled lang.!
• MODIFY tasks/environment
• PROVIDE/INSTRUCT on use of AE
• FABRICATE splints/assistive devices
• DETERMINE safety of something
• TEACH compensatory skills
• IMPROVE performance areas through remediation approaches

Question 9

How to address PAIN in Assessment

Answer 9

Note how pain has impact on performance, or any discrepancies.