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Occupational Therapy SOAP Notes: Template and Worked Examples

Authors
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    Angela Mariani
    Twitter

Occupational therapist completing documentation

Introduction

An occupational therapy SOAP note records the client's perspective, the observable session details, the therapist's interpretation and the next plan under four headings: Subjective, Objective, Assessment and Plan.

The structure is simple. The clinical reasoning inside it is not. A useful OT SOAP note should connect the session to occupational performance and the client's goals without blurring reported information, observed facts and professional interpretation.

This guide includes a copyable template, two fictional examples and a review checklist. It is general educational information, not legal, clinical governance, funding or professional advice. SOAP is a documentation framework rather than a universal regulatory requirement. Follow your profession, employer, funder, insurer and jurisdiction-specific requirements.

What does SOAP stand for in occupational therapy?

  • Subjective: what the client, parent, carer or another relevant person reports.
  • Objective: what the therapist observed, measured or did during the session.
  • Assessment: the therapist's interpretation of the subjective and objective information.
  • Plan: the agreed or proposed next actions.

SOAP helps readers see where information came from. For example, "the client reported no falls this week" belongs in Subjective. A balance result observed during the session belongs in Objective. The therapist's interpretation of what those facts mean for showering safely belongs in Assessment.

The Australian Health Practitioner Regulation Agency's health-record guidance says that clear and accurate records support continuing care. It also reminds practitioners to consider their Board's expectations and the health-record and privacy laws that apply in their state, territory or nationally. The Occupational Therapy Board of Australia links the current code, competency standards and health-record resources for registered occupational therapists.

Copyable occupational therapy SOAP note template

Use this as a starting point and adapt it to the setting, client, organisation and purpose of the record.

Session details
- Date and time:
- Location or mode:
- People present and their roles:
- Relevant client goal or purpose of the session:

Subjective
- What did the client report in their own words?
- What did a parent, carer or other person report, and who said it?
- What changes, concerns, priorities or goals were described?

Objective
- What activities or interventions occurred?
- What was directly observed or measured?
- What assistance, cueing, equipment or environmental setup was used?
- What response or result was observed?

Assessment
- What do the reported and observed findings mean for occupational performance?
- What progress, barriers or patterns are supported by the evidence above?
- What clinical reasoning connects the session to the client's goals?
- What remains uncertain or requires further assessment?

Plan
- What will happen next, by whom and when?
- What will be continued, changed, trialled or reviewed?
- Are there agreed actions for the client, family, team or therapist?

If your organisation requires other fields—such as consent, risk, service duration, funding information, incident details or a signature—add them explicitly. Do not assume that the four SOAP headings cover every record-keeping requirement.

How to write each section

Subjective: attribute the information

Subjective does not mean unreliable. It means the information was reported rather than directly observed in the session.

Useful entries identify the source and preserve the client's priorities. For example:

  • "Client reported needing one rest break while preparing dinner on three evenings this week."
  • "Parent reported that morning dressing took approximately 20 minutes on school days."
  • "Client stated, 'I want to be able to get the bus on my own.'"

Avoid turning a report into a fact without attribution. "The client is independent with dressing" means something different from "the client reported dressing independently this week."

Objective: record observable and measurable detail

Objective should let the reader understand what occurred without guessing. Depending on the setting, useful detail may include:

  • the task, context and duration
  • repetitions or trial results
  • assistance and cueing levels
  • equipment or environmental changes
  • standardised assessment results, including the measure used
  • observable responses relevant to the task

Use the amount of detail needed for the purpose of the record. Avoid inserting a measurement that was not taken or choosing precise-sounding language that the source information does not support.

Assessment: show the OT reasoning

Assessment is more than a second description of the session. It explains what the information may mean for the person's occupations, participation and goals.

A strong assessment:

  • interprets the evidence already recorded in Subjective and Objective
  • identifies supported progress or barriers
  • connects findings to occupational performance
  • states uncertainty rather than filling gaps with assumptions
  • explains the reasoning for the next step

Be careful with cause-and-effect claims. If the session shows an association but not a confirmed cause, use language that keeps that uncertainty visible.

Plan: make the next action clear

The plan should answer what happens next. It might cover the next session focus, a home or workplace trial, communication with another person, further assessment, equipment follow-up or a review date.

"Continue OT" is usually less useful than a specific action. Record what will continue, what will change, who is responsible and any timing that has actually been agreed.

Fictional example 1: paediatric dressing goal

The following example is fictional and simplified for teaching. It is not a model of the required content for every paediatric record.

Relevant goal: increase independence with school-morning dressing.

Subjective

Parent reported that the client fastened the two large buttons on their school shirt with verbal prompting on two mornings this week. Client stated, "The little buttons are harder."

Objective

During a 45-minute clinic session, the client practised fastening and unfastening five 20 mm buttons on a dressing board. The client fastened two of five buttons independently and three with one or two verbal cues. On a second trial, the client independently fastened three of five. The therapist graded the task by stabilising the board and then removing that support.

Assessment

The client demonstrated improved task completion within the session when the board was stabilised and verbal cues were reduced. Difficulty aligning the smaller button with the opening continued to affect independence. Practice should remain linked to the client's school shirt before assuming the dressing-board performance transfers to the morning routine.

Plan

At the next session, practise with the client's school shirt and compare performance with and without garment stabilisation. Parent and client agreed to one short practice trial before school on two days and to note the cueing required.

Fictional example 2: adult meal-preparation goal

This example is also fictional and simplified.

Relevant goal: prepare a simple breakfast with less fatigue.

Subjective

Client reported needing to sit down twice while preparing breakfast on most mornings this week. Client said the most tiring tasks were collecting items from low cupboards and standing at the bench.

Objective

During a home visit, the client prepared cereal and a hot drink using their usual kitchen setup. The client stood at the bench for six minutes, then chose to complete the remaining preparation while seated. One verbal cue was provided to place frequently used items together before starting. No loss of balance was observed during the task.

Assessment

The observed task supports the client's report that sustained standing contributes to difficulty completing breakfast. Completing the later steps while seated reduced continuous standing, while collecting items from separate storage areas added movement before preparation began. One session does not establish how the strategy will perform across different days or fatigue levels.

Plan

Client agreed to trial storing breakfast items together and using the existing chair for preparation over the next week. Review perceived effort, rest breaks and any safety concerns at the next appointment before deciding whether further environmental changes are appropriate.

OT SOAP note review checklist

Before finalising the record, ask:

  • Is each reported statement attributed to the client, carer or other source?
  • Does Objective contain only information that was observed, measured or completed?
  • Are assistance, cueing, context and units clear where they matter?
  • Does Assessment interpret the evidence rather than introduce new facts?
  • Is the connection to occupational performance or the client's goal explicit?
  • Are uncertainty, missing information and limitations visible?
  • Does Plan state the next action, responsibility and timing where known?
  • Have copied-forward details been checked against the current session?
  • Have unnecessary identifying or sensitive details been removed?
  • Does the note meet the applicable Board, employer, funder, privacy and local requirements?

A practical final test is whether another authorised practitioner could understand what was reported, what occurred, what you concluded and what is meant to happen next.

Common SOAP note mistakes

Mixing interpretation into Objective

"Poor motivation" is an interpretation, not a direct observation. Record what was seen or reported first, then explain the supported interpretation in Assessment.

Adding details that were not captured

A polished sentence can still be inaccurate. If a result, time, assistance level or client statement was not recorded, do not invent it to make the note feel complete. Mark the gap or verify the information.

Repeating Objective in Assessment

Assessment should explain why the findings matter. If it merely restates the task and result, the clinical reasoning is missing.

Writing a plan no one can act on

Specify the next step that was actually agreed. Avoid adding referrals, equipment, frequencies or home tasks that were not discussed or clinically determined.

Treating a template as a compliance guarantee

A template can improve consistency, but it cannot determine all the obligations that apply to a practitioner or service. Check current professional, legal, funding and organisational requirements.

Using AI to draft an OT SOAP note

AI can help organise source information into an editable structure, but it does not take responsibility for the record. Ahpra's guidance on AI in healthcare says practitioners must apply human judgement to AI output and remain responsible for checking the accuracy and relevance of AI-generated records. It also highlights consent, transparency, privacy, tool limitations and local governance.

A safer workflow is:

  1. Capture the relevant source information and identify who reported each item.
  2. Choose the appropriate template for the service and purpose.
  3. Generate or assemble a draft without adding unsupported detail.
  4. Compare every statement with the source notes, observations and measurements.
  5. Correct errors, add the therapist's own reasoning and remove unnecessary information.
  6. Finalise the record only after the responsible clinician approves it.

Everbility's occupational therapy documentation software lets occupational therapists bring notes, dictation and source documents into an editable workspace, use a suitable template, and review the resulting draft before export. The occupational therapist remains responsible for verifying the evidence and applying their professional judgement.

For a broader software-evaluation process, see How to Evaluate AI Software for Clinical Practice. If you are designing reusable structures, Why Templates Matter in Therapy Documentation explains where templates help and where clinician judgement still matters.

Frequently asked questions

Are occupational therapists required to use SOAP notes?

Not universally. SOAP is one way to structure a clinical note. Your required format may come from your professional obligations, jurisdiction, employer, service, funder or record system. Check the current requirements that apply to your work.

How detailed should an occupational therapy SOAP note be?

Include enough relevant information to support continuity of care, explain the clinical reasoning and make the next action clear. More text is not automatically better. The purpose and context of the record should determine the appropriate detail.

Can I use the same SOAP note template for every OT setting?

The four headings can be reused, but the fields and detail may need to change. A brief community progress note, an acute-care entry and a funding report serve different purposes and may have different requirements.

Can AI write a SOAP note from a session transcript?

AI can create a draft, provided the tool and workflow are appropriate for the setting. The responsible practitioner still needs to address consent and privacy, check the draft against the source, correct unsupported statements and apply their own clinical reasoning before using the record.

What is the difference between Objective and Assessment?

Objective records what was observed, measured or completed. Assessment explains what those findings may mean for occupational performance, progress, barriers and the plan.

Put the template into an editable workflow

A good template removes blank-page friction. A good review process makes sure the final note remains accurate, relevant and grounded in the session.

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