Documentation for therapy services can be a time-consuming yet essential component of service delivery. Many practitioners and clinicians attempt to streamline their daily note process. Some critical details should not be overlooked, though it is still possible to create a concise note while including everything that reimbursement experts need to see.
Many professions, including occupational therapists, physical therapists, speech-language pathologists, ABA therapists, and others, use SOAP notes for their daily sessions. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. SOAP notes are valuable because they provide information about different therapy components, and since therapists use them wisely, the interdisciplinary team can use them as a means of timely communication.
S: Subjective: What is the client saying about their experience?
Subjective information may include reports of pain, challenges since the last session, or what the client shares they can or cannot do. You may record behavior during the session for pediatric clients, including arousal level and engagement in therapy. You can also include reports from the client’s family or teachers.
O: Objective: What are you observing? What data can you collect?
Include any compensatory strategies your client uses, physical or cognitive strategies for participation, and data you collect. The objective section could include the percentage of trials completed correctly and the client’s level of support needed to perform the activity. If your client needed any adaptive equipment, assistive technology, or modification of a task, include that information here as well. It is vital to make sure that you focus on the active experience of the client rather than the therapist. For example, note that the “Client needed moderate physical assistance for bathroom mobility” rather than “Provided moderate physical assistance to the client.”
A: Assessment: What is your interpretation?
Consider what you wrote in the subjective and objective categories. What does this mean? You’ll use your clinical expertise to interpret the information into an analysis of the client’s performance. Note any improvement, regression, or progress toward your client’s goals. Refer back to the subjective and objective categories to support your assessment.
P: Plan: What is going to happen next?
Include the frequency, duration, and location of recommended services. If you are recommending discharge, include specific information about recommendations for follow-up. Otherwise, include detailed information about your intervention plan and how you will use it to address the problems noted in this session. Daily documentation and SOAP notes are a tool that is essential to all parties involved in therapy:
- The client: Timely and thorough documentation informs the therapist that they are making progress and are responsive to the selected interventions.
- Professionals: Since SOAP notes are commonly used in healthcare, SOAP notes can help the interdisciplinary team communicate quickly and effectively.
- Payors: Reimbursement parties can be assured that the intervention is effective and taking place.
- The therapist: Recording comprehensive notes allows the therapist to provide ethical, evidence-based service and meet the client’s ongoing needs.
CBS Therapy is the premier provider of school-based and pediatric special education staffing services in the Northeast.
