SOAP Notes: A Learning Curve

Hey readers! Last week I shared my experience leading my first OT group, so now I am going to talk about the assignment that went along with it: writing a SOAP note! For those who don’t know, SOAP notes are detailed yet concise records of documentation that health providers write to communicate patient goals, progress, interventions used, and plans for future interventions to other healthcare providers, insurance providers, the patient and their family, etc. “SOAP” stands for subjective, objective, assessment, plan.

Let’s talk about what a SOAP note may look like in occupational therapy. The subjective section is usually comprised of a direct quote – something that the patient said during the OT session that points to a concern regarding occupational performance, progress made, feelings towards therapy, etc. The objective section should be comprised of quantifiable or measurable data that describes what the client did during the OT session. The assessment section includes a problem statement, progress made, barriers affecting performance, and a justification for continuing therapy. Finally, the plan describes the purpose for continued therapy along with the duration and frequency of OT sessions.

Writing My First SOAP Note

I’m not going to lie…I did not do very well on my first SOAP note. Let me explain:

My assignment was to write a SOAP note on one of my peers after we participated in an OT group led by a faculty member. My peers and I were the “clients” participating in the mental health group. There were two main reasons why I got a bit lost in writing my SOAP note. First, I found it challenging to write a SOAP note about one of my classmates. This was because my classmate did not really need OT. I felt like I was grasping at straws trying to come up with deficits and barriers to occupational performance, and then when I thought of something to write about it I had to exaggerate what she did in order to make it seem like she needed OT. The second reason why I found this assignment to be challenging was because mental health interventions are not as “black and white” as other OT interventions. For example, it is much more observable and quantifiable to say that a client “took two steps” or “buttoned three buttons independently” than quantifying mental health (in my opinion).

For these two reasons, I lost the purpose of the OT session in my SOAP note. Instead of describing exactly how the student participated, I vaguely wrote that the student participated without going into detail about the actual intervention. If that note had been presented to insurance, it would not have been justifiable and they would have had no idea what the intervention looked like. For insurance alone, it is so important to be able to write strong SOAP notes in order to have your sessions covered. It is also important for communication among healthcare providers. For example, if I call out sick one day and another OT has to cover my caseload, she/he will need to know what I did in the last session and what to do that day in order to provide optimal care to my patients.

What I Learned

The faculty member who supervised my group and graded my SOAP note was really helpful and sat down with me to talk about my note. She talked me through getting back to the purpose of the group and got me to say out loud what I should have written on paper. Learning how to write a good SOAP note is definitely a learning curve, and I still found my second one challenging, but I am getting there! She even called my revised note and the second one “fabulous!”

Sample SOAP Note

*This SOAP note has not yet been graded and I am not a professional OT. Do not use for reference.*

Here is a sample SOAP note! I wrote this one after the group that I led on self-doubt, so this is my second SOAP note ever. (So be nice please!)

S: Student stated, “my self-doubt motivates me to do better, but it is always in the back of my mind.” Student states that her thoughts of self-doubt revolve primarily around school and affect her ability to participate in classroom discussions and apply for desired roles.

O: Student participated in 45 minute OT group in for identification of thoughts of self-doubt and development of coping strategies to replace doubts with affirmations. Student arrived on time and dressed appropriately. Student independently identified school as 1 area of self-doubt and reported that doubts present a barrier for participation. Student independently identified 3 affirmations to write on a meditation stone. Student groaned and stated “it’s not the pen, it’s the user of the pen” when 3 different pens stopped working while she was writing. Student independently participated in a 2-minute guided meditation for repeating affirmations to self. Student reported that repeating affirmations to self felt uncomfortable at first, then stated “wow, it just came full circle” when she realized that she is meant to be in graduate school despite feelings of self-doubt. Student reported that she previously did not use coping strategies for thoughts of self-doubt, but that “this proves that maybe I should start writing things down.”

A: Student’s thoughts of self-doubt impact her ability to participate in school-related activities as evidenced by frustration and blame of self while using faulty pens. Student demonstrated progress when she realized that despite her own barriers of self-doubt, she has the capacity to participate in school. However, student continues to doubt herself in her abilities to perform tasks related to school, as observed while student was writing affirmations on a meditation stone. Student demonstrated good rehab potential by identifying doubts and affirmations independently, engaging in a meditation and group discussion, and realizing the benefit of coping with self-doubt. Student would benefit from continued skilled OT in the development of coping strategies for defeating self-doubt in order to facilitate participation in desired roles and activities at school.

P: Student will attend 1-45-minute OT session per week for 8 weeks to address self-doubt in order to effectively participate in school-related activities.

How did your first experience writing SOAP notes go? Comment below! Thanks for reading!

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