Free SOAP Note Generator for Occupational Therapy
Generate complete OT SOAP notes from your session keywords. Our AI understands functional assessments, ADL/IADL performance, adaptive equipment recommendations, and occupational therapy documentation conventions.
OT SOAP Notes
Occupational therapy SOAP notes focus on functional performance and the patient's ability to engage in meaningful daily occupations. Unlike physical therapy, which emphasizes impairment-level measurements, OT documentation centers on how impairments affect the patient's ability to perform activities of daily living (ADLs), instrumental activities (IADLs), work tasks, and leisure activities.
Section Guide for OTs
S - Subjective
Document the patient's self-reported functional concerns, daily living challenges, goals for independence, and perception of progress. Note specific activities they are having difficulty with and their motivation for treatment.
O - Objective
Record functional performance levels (independent, min/mod/max assist, dependent), UE function (strength, coordination, sensation), cognitive assessments, assistive device use and effectiveness, treatment activities performed, and task completion with specific assistance levels.
A - Assessment
Provide clinical analysis of functional progress, barriers to independence, occupational performance patterns, and rehabilitation potential. Connect observations to treatment goals and justify the need for continued skilled OT services.
P - Plan
Outline treatment modifications, adaptive equipment recommendations, home program updates, caregiver training needs, environmental modification suggestions, frequency/duration of visits, and discharge planning.
Common OT Assessment Tools
| Tool | Purpose |
|---|---|
| FIM | Functional Independence Measure |
| Barthel Index | ADL independence rating |
| COPM | Canadian Occupational Performance Measure |
| Grip/Pinch Strength | Hand function assessment |
| MoCA | Montreal Cognitive Assessment |
| 9-Hole Peg Test | Fine motor dexterity |
OT SOAP Note Example
S - Subjective
Patient is a 68-year-old male, 3 weeks status post left CVA with right hemiparesis. He reported frustration with dressing, stating he "can't get buttons done" and needs his wife's help for most morning routine tasks. He expressed a strong desire to regain independence with self-care activities and return to driving.
O - Objective
UE dressing required moderate assistance for donning button-down shirt (primarily for button manipulation and sleeve management on the affected side). Patient completed button/zipper practice board with 3 of 6 buttons independently using a button hook after instruction. Right hand grip strength 12 lbs (left dominant, 45 lbs). FIM self-care score improved from 3 to 4 (moderate to minimal assistance). Patient demonstrated ability to use adapted techniques for one-handed sock donning with verbal cues.
A - Assessment
Patient is making functional gains in self-care tasks as evidenced by FIM score improvement. He is responding well to compensatory strategies and adaptive equipment training. Fine motor coordination of the right hand remains significantly impaired, limiting bilateral task performance. Patient is motivated and demonstrates good carryover of learned techniques between sessions.
P - Plan
Continue OT 5x/week during inpatient rehabilitation. Order button hook, long-handled shoe horn, and sock aide for patient use. Progress dressing training to include lower body dressing and shower routine. Initiate kitchen task training (meal prep, utensil use). Caregiver training session with wife scheduled for Thursday to review home safety modifications and adaptive equipment use. Short-term goal: minimal assistance with UB dressing within 2 weeks.
Frequently Asked Questions
How do I document assistance levels in OT notes?
Use the standard FIM assistance levels: Independent (7), Modified Independent (6), Supervision (5), Minimal Assistance (4, patient does 75%+), Moderate Assistance (3, patient does 50%+), Maximum Assistance (2, patient does 25%+), Total Assistance (1). Be specific about which aspects of the task required assistance.
What is the difference between OT and PT SOAP notes?
OT SOAP notes focus on functional performance and occupational engagement (how impairments affect daily activities), while PT SOAP notes emphasize impairment-level measurements (ROM, strength, gait). OT documentation centers on ADL/IADL performance, adaptive strategies, and environmental modifications. Both professions may measure similar outcomes but frame them differently based on their scope of practice.