SOAP Notes: OBJECTIVE

Question 1

What is the “O” in the SOAP note?

Answer 1

OBJECTIVE. This is where you write a synopsis of the entire encounter/session. It is:
• Measurable/quantifiable data
• What you observe patient doing
• Your skilled observations about functional movement, skills, patterns, etc.

Question 2

What is the formulaic sentence that begins the O in SOAP?

Answer 2

“Client participated in ____ (#)-minute session in _____(setting)for _____ (purpose of intervention session).”

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

Question 3

What to include in the O section:

Answer 3

• Give KEY DETAILS (which type of ROM? Which level assistance? Which side of UE? Can include test results in chart)
• Show the need for OTA skill (formulaic sentence can establish this)
• Indicate active client engagement (neither you or pt. should be passive!)
• Identify specific skilled OT services implemented
• Show justification for skilled therapy (use wording such as: Promote, Teach, Adapt, Administer, Determine Safety, Enhance, Modify, Evaluate…)
• Show how tx is specific to OT (that it is not overlapping with other disciplines, ie: PT)
• Connect non-occupation exercises/PAMS, etc. to an occupational function (ie: ___ as way to work on sink grooming goal).
• Indicate/confirm client’s and/or caregiver’s understanding

Question 4

2 methods of organizing your Objective note

Answer 4

**Always start with Formula sentence! Then choose:

1) CHRONOLOGICALLY: Discuss each event in the order it occurred in the session (in a paragraph format).
2) CATEGORICALLY: Use your judgment to break down session into skilled/appropriate sections with subheads. Use OTPF categories (occupations, client factors, performance skills, etc.) as a starting point. Can also be things like ROM, ADLs, AEs, Sequencing, Safety, etc. Match the client’s tx plan.

Question 5

Assist Levels

Answer 5

Be specific about assistance used. Physical? Verbal? Visual?

Indicate Amount:
Total: requires 76-100% assist
max: requires 51-75% assist
mod: requires 26-50% assist
min: requires 25% or less assist
SBA: “standby”- one person nearby for safety
CGA: “contact guard assist” – requires hand contact due to LOB
Set-up: requires set-up of items first
I (in circle): independent (no assist)

Ex: “close supervision,” “Line of sight supervision,” “Required 5 verbal cues”

Question 6

CGA

Answer 6

Contact Guard Assist: when patient requires a hand contact during activity due to occasional LOB; protective safeguard.

Question 7

SBA

Answer 7

Standby Supervision/Assist: when a patient needs someone supervising for safe and effective task performance.

Question 8

How to address PAIN in Objective

Answer 8

Any observable data about pain is addressed in O; address pain in some way, such as teaching deep breathing to reduce pain.