Occupational therapists are accountable for documenting health records as regulated health professionals. Health records are legal documents and require all aspects of occupational therapy practice to be recorded, such as interventions and plans made during the therapist-client relationship. The Subjective, Objective, Assessment and Plan (SOAP) note is a widely used documentation method for healthcare professionals, including occupational therapists. The SOAP note assists healthcare workers to document in a structured and organized format.
The Subjective (S) heading documents client experiences, their feelings and views. For example, it may include a statement such as, "Client reports that he cannot get dressed." The S section may also include information such as a client's medical history, activities of daily living, and level of functioning. The Objective (O) section documents objective data obtained from measurements or observations. For example, it could include data from manual muscle tests or active and passive range of motion assessments. The Assessment (A) section involves synthesizing information obtained in the S and O sections and often involves "fitting together" all of the information. The Plan (P) section of the note details additional testing and interventions related to the client's care. It outlines the steps that will be taken to address the client's care in the future, such as short and long term goals.
Some important tips to remember when documenting include:
- records are understandable and legible
- every entry is signed and dated
- documentation is completed in a timely manner
- client information is current and accurate
- the rationale for therapy recommendations
- informed consent is obtained for all throughout therapy and for the collection, use and disclosure of personal health information
Reference: Podder V, Lew V, Ghassemzadeh S. SOAP Notes. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482263/