How I Write SOAP Notes for Occupational Therapy

SOAP Notes for Occupational Therapy

If I had a dollar for every time I heard an occupational therapist say 'SOAP notes don't work for what we do,' I could retire tomorrow.

And you know what?

They're not entirely wrong if they're trying to fit complex, holistic OT interventions into a rigid medical template.

They're not.

Quick tip:

I fixed writing soap notes and built a tool that does this at scale. Over a 100 reviews. HIPAA compliant. Head over to soapnotes.com to get started.

Let's Talk SOAP Notes

Here's a fun fact that might surprise you: SOAP notes have been around since before the moon landing.

Dr. Lawrence Weed introduced them in 1968 as part of his revolutionary idea that medical records should actually make sense to anyone reading them.

Revolutionary concept, right?

Weed's vision was simple but powerful: every healthcare encounter should tell the same story in the same order.

What the patient says (Subjective), what you observe (Objective), what you think it all means (Assessment), and what you're going to do about it (Plan).

Why SOAP Stuck Around

There's a reason SOAP notes became the backbone of healthcare documentation worldwide.

They work. They create a logical flow that helps clinicians think systematically about patient care. They make information findable. They satisfy regulatory requirements. They tell a complete story.

But—and this is a big but—they were designed for medical diagnosis, not rehabilitation and habilitation.

That's why they can feel clunky when you're trying to document the function-focused work we do in OT.

The Four Sections

One thing I love to employ is the perception that the four section in a SOAP note are chapters in the story about your client's journey:

Let me expatiate...

• Subjective: The client's voice. Their concerns, goals, frustrations, victories. What matters to them about getting better.
• Objective: Your trained eyes and hands at work. What you measured, observed, tested, and witnessed during the session.
• Assessment: Your clinical reasoning on full display. The "so what?" that connects observations to outcomes.
• Plan: Your roadmap. Where you're headed next and how you'll get there.

When you think about it this way, SOAP notes become less about checking compliance boxes and more about crafting a narrative of human progress.

How I Navigate Around SOAP Notes for Occupational Therapy

Here's the thing about SOAP notes in OT—everyone's doing them, but most people are doing them the hard way.

Most people are either overwriting, underwriting, or spend time using the wrong system.

Here's how to go about them the easy way.

The Two Approaches That I love:

1. Use soapnotes.doctor.
2. Write them using these 3-layer approach

Approach One: Use SOAP Notes Doctor

Here's how it transforms your workflow:

Getting Started Takes Under 5 Minutes

Remember when EMR systems promised to make your life easier but required a PhD in computer science to operate? We went the opposite direction. SOAP Notes Doctor works in any modern web browser—no downloads, no IT department involvement, no three-hour training sessions.

You literally log in and start recording.

The Magic Happens During Your Session

Instead of splitting your attention between your client and your clipboard, you simply click "Start Recording" and focus entirely on therapy. The AI captures everything—your questions, their responses, your clinical observations, even those spontaneous moments when breakthrough happens.

Want to maintain patient history? Just search for their name before starting. The system pulls up previous sessions, creating continuity that manual notes often miss.

From Session to Professional Note in Minutes

Here's where it gets beautiful: when you click "Save This Session," our AI thinks like a clinician.

It automatically organizes information into proper SOAP format, capturing not just what was said, but the clinical reasoning behind your decisions.

The Tailorr Feature: Your Documentation Personality

Every OT has their own style—some are detailed storytellers, others are concise and clinical.

The Tailorr feature is our attempt to make sure our product adapts to everyone accordingly.

You can add custom tags, modify section emphasis, and ensure every note reflects your professional voice.

Working in a pediatric clinic? Tailorr can emphasize sensory integration aspects. Hospital-based? It can focus on discharge planning elements. The AI adapts to you, not the other way around.

You just have to tell it to.

Approach Two: The Manual Way (that actually saves time)

If you love writing longhand and have hours to spare, go wild. For the rest of us, here’s the simple system I use—the “Three-Layer Approach.”

Phase 1: Rapid Capture — during the session

Do. Not. Write. Beautiful. Sentences. Your client is working; you are collecting gold. Use shorthand, abbreviations, and bullets you can expand later. I keep a tiny template on my clipboard:

S — what they say:

“Shoulder at 6/10 after folding laundry.”

“Still scared of the tub transfer.”

“Goal: pick up grandson without pain.”

O — what they did (and how much help they needed):

LB dressing with sock aid, min A to thread LLE.

Sit-to-stand 5x in 18s, hands on chair arms.

Kitchen task: reached 2nd shelf with reacher, 1 verbal cue for posture.

Toilet transfer CGA using grab bar; no LOB.

Grip strength: R 22 kg / L 18 kg. TUG: 19s. 9-HPT: R 28s / L 32s.

A — what it means:

Progressing toward LB dressing mod I; slowed by fatigue after 8 min standing.

Pain limits overhead reach; compensates with trunk lean (safety risk).

Benefits from single-step cues; memory carries over across tasks.

P — what’s next:

Train tub bench transfer + energy conservation for meal prep.

Upgrade TheraBand to green; review HEP (3x/week, 10 reps).

Order long-handled sponge; send caregiver handout.

Coordinate with PT about gait belt use for bathroom transfers.

Keep it messy. Keep it fast. Future-you will send you a fruit basket.

Phase 2: Structured Expansion — right after the session

This is where most notes go to die: people wait hours and the details evaporate. Set a 3–4 minute timer the second your client leaves and turn those bullets into real SOAP sentences.

Example glow-up (takes 30 seconds):

Bullet: “LB dress sock aid min A; 2 cues posture”

Expanded: “Client donned socks with sock aid, min A to thread LLE. Required two single-step cues to maintain upright posture and avoid trunk compensation.”

While it’s fresh, you remember it was the left leg, not “legs.” You remember it was two cues, not “a few.” That’s the difference between “meh” documentation and insurance-ready notes.

Phase 3: Quick Quality Pass — before you sign

Read it like you’re the covering therapist walking in cold tomorrow. Can you treat from this? Does it clearly show skilled OT is still needed? I run this 30-second checklist:

Clear S/O/A/P?

Assist levels and measurable outcomes included?

Safety, fatigue, or pain addressed?

Plan ties directly to the problems you found?

Read one paragraph out loud—does it flow, or trip over itself?

If it passes, sign and move on.

Why most manual SOAP workflows flop (and how to fix them)

1. The “Perfect First Draft” trap

Trying to write an insurance-ready essay during treatment is like composing a novel on a treadmill. Don’t. Capture data now; craft later. Fix: bullets in session, sentences after.

2. Wobbly SOAP structure

Random order = missed details. Create mini-templates by diagnosis and stick to them. Example for stroke follow-up: ADLs → functional reach → transfers → cognition/attention → safety. Same order, every time. You’ll cover ADL performance, cognitive status, and safety without hunting for scraps.

3. Trusting memory for the tricky bits

“I’ll remember the assist level later.” You won’t. Not after three more clients and two phone calls. Fix: write the assist level + cue type + number immediately (e.g., “min A, 2 verbal cues”). Expand while the chair is still warm.