Assessment and Therapy 1

SOAP Note writing- examples

 

Writing SOAP notes is a skill which you can learn.

I recommend you study from the book entitled Documentation Manual for Writing SOAP Notes in Occupational Therapy by Sherry Borcherding.

Below are some examples from other students as a guide. They are not all perfect, but provide some good examples for you to learn from.

 

Child's Name Here                                           Date of therapy here

S: Mother reports child slept well last night. Child was alert and attentive during therapy today. Mother states she has done the home exercise program three times this week and she thinks her daughter is moving better.

O: Tone normalization activities- alternating shoulder and hip rotations, deep pressure and stretching to normalize tone and obtain passive stretch 

Sit balance activities- on therapy ball with forward propping of arms and trunk support. Long sit on mat-stretch ham strings,  worked on active reaching to side and up to shoulder flex of about 90. while supporting with one arm.  Holding bilaterally and transferring toy hand to hand with verbal and physical cues.

Quadruped activities with UE weight bearing to inhibit extension patterns. Max a to maintain position and look at bubbles. Pushing into extension at times and required more inhibition.

Home Exercise Program reviewed with mother leading the demonstration and therapist providing feedback on the techniques. Still needs some cues to slow down and stretch well. 

A: Child demonstrates improved equilibrium reactions to  maintain long sit with support from therapist at hips. Hand to hand transfer still requires max a from therapist to release and open with right hand, can do with min assist with left hand. Improved attention span for about 4-5 mins today. Mother more comfortable with completing home exercise program and required only verbal cues today.

P: Continue therapy 3x week with focus on improving motor control to promote play skills and functional mobility.

                                                        Donna Wooster, MS, OTR/L, BCP

                                               

 

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Child's Name                                 Date

S: Accompanied to OT by Grandmother and sister. Grandmother reports she will be caring for child 2 days per week now that Mom has returned to work. Grandmother expressing need for instruction on dressing for child.

O: Don/ Doff Shirt- t-shirt style- with child sitting with legs in ring sit position and support provided intermittently at hips and back. Child and grandmother instructed in hemi-dressing techniques to don on involved side (L) first and remove it last. Child required some assist to pull down overhead.

Don/doff pants for toileting-pulling from hips to knees and back up with min a and some verbal cues. Today's pants had buttons which were too difficult for child to complete while standing. Suggested zip or elastic waist style to promote independent. Child can stand and maintain balance while pulling pants up/down with non involved hand. Can pull up and down the "pull up" style underwear. Grandmother practiced with child and therapist gave feedback to promote independence at her home. Grandmother will purchase reducer ring for her bathroom. Information provided. Grandmother reports limited success with toilet training. She will promote use of toilet with sticker reinforcers for keeping dry and use consistent timed toileting program that mom and school have agreed upon.

Play with crayons and markers to promote bilateral hand skills and writing skills. Sitting at child sized table with appropriate posture.  Could maintain L hand open and holding paper with verbal cues only. Drew with R static tripod grasp on large marker. Could imitate with cues a -,l,o,+ designs. Worked on connecting dots to make a square. She enjoyed this activity.

A: Child is demonstrating progress with hemi dressing techniques when appropriate clothing is provided to encourage independence. Improved ability to use involved left hand to stabilize paper noted today. Improving pre-writing skills to progress to the square. Grandmother to carry over dressing and toileting when she is caring for child.

P: Continue therapy two times weekly with emphasis on motor control to improve functional self care and academic readiness. Grandmother will try to come to therapy at least one per month to learn new techniques.

         Cindy Smith, OTS