14 min read

Occupational Therapy SOAP Note Examples (With Templates)

Dr. Medeline Yost

Chief Medical Officer, Augustun

Published July 4, 2026

Updated July 4, 2026

On this page

What Is a SOAP Note in Occupational Therapy?
SOAP vs DAP vs BIRP: Which Format Should OTs Use?
Occupational Therapy SOAP Note Template
6 OT SOAP Note Examples
How to Write an OT SOAP Note Faster
Let an AI Scribe Handle the Note
Final Thoughts
FAQ

SOAP notes are the backbone of occupational therapy documentation. Every session you run — whether it is an outpatient hand therapy visit or an acute care bedside evaluation — needs a note that tells a clear story. The note shows what the patient said, what you measured, what you think about their progress, and what comes next. Get that story right and insurance pays, the next therapist picks up where you left off, and your license stays safe.

The tricky part is that every OT setting looks a little different. A rotator cuff repair note needs ROM measurements and assist levels. A mental health note needs participation observations and safety planning. And a burn rehab note needs edema readings and splint compliance. If you try to write the same cookie-cutter note for every patient, something important gets left out.

This guide gives you six complete SOAP note examples you can adapt to your own caseload, a blank template to copy, and a quick comparison of SOAP, DAP, and BIRP formats so you know which one fits your setting. For a broader look at OT note types — evaluations, progress notes, discharge summaries, and cheat sheets — see our companion OT documentation guide.

What Is a SOAP Note in Occupational Therapy?

A SOAP note is a four-part clinical note. The letters stand for Subjective, Objective, Assessment, and Plan. Each section has one job:

Subjective — What the patient or caregiver tells you. Pain complaints, functional concerns, how they felt since the last visit.
Objective — What you observe and measure. ROM, strength, assist levels, task performance, standardized test scores.
Assessment — Your clinical reasoning. Is the patient progressing? What barriers remain? Why is skilled OT still needed?
Plan — What happens next. Treatment frequency, goals to target, equipment to order, referrals to make.

OTs use SOAP notes because they are fast, organized, and accepted by virtually every payer and facility. The format also makes it easy for another therapist to take over your caseload — they can read one note and know exactly where the patient stands.

The Objective section is where OT SOAP notes differ most from other disciplines. Physicians might focus on lab values and imaging. Physical therapists emphasize gait and balance metrics. OTs zero in on how the patient performs meaningful daily tasks — dressing, feeding, grooming, handwriting, cooking — and the specific assist levels, adaptive equipment, and environmental modifications needed to close the gap between where the patient is and where they want to be.

SOAP vs DAP vs BIRP: Which Format Should OTs Use?

SOAP is the default in most OT settings, but it is not the only option. Two other formats — DAP and BIRP — show up in certain practice areas. Here is a side-by-side comparison:

Format	Sections	Best For	Common Settings
SOAP	Subjective, Objective, Assessment, Plan	Detailed clinical reasoning with measurable data	Outpatient, acute care, inpatient rehab, SNFs, home health
DAP	Data, Assessment, Plan	Shorter notes that combine subjective and objective into one section	School-based OT, mental health OT, community programs
BIRP	Behavior, Intervention, Response, Plan	Session-focused notes that emphasize what the therapist did	Behavioral health, some state-funded programs

SOAP is the safest choice for most OTs. It gives you the most room to show skilled reasoning and measurable progress, which is what insurance reviewers look for. DAP works well in school-based and mental health OT because those settings lean toward narrative documentation and the sessions are often shorter. BIRP is less common in OT — you are more likely to see it in counseling or social work — but some behavioral health programs require it. When in doubt, ask your facility which format they prefer. If they have no preference, stick with SOAP.

Occupational Therapy SOAP Note Template

Copy this blank template and fill in the brackets for your next session. It works for most OT settings — just add or remove lines to match your facility's requirements.

OT SOAP Note — Blank Template

Subjective: Patient/caregiver reports: [quote or summary of patient's complaint, functional concern, or status update]. Pain level: [0–10]. Patient states [relevant change since last visit]. Prior level of function: [brief description].
Objective: Diagnosis: [ICD-10 code and description]. Session duration: [minutes]. Setting: [outpatient / acute care / inpatient rehab / SNF / home health]. Vitals (if applicable): BP [value], HR [value]. ROM: [joint] [AROM/PROM] [degrees]. Strength: [muscle group] [grade /5]. Assist levels: [task] — [independent / supervision / min A / mod A / max A / dependent]. Standardized test: [name] — [score]. Functional task: [description of activity, cues given, number of reps or trials, accuracy]. Equipment used: [adaptive device or modality].
Assessment: Patient demonstrates [improved / stable / declined] performance in [area]. Compared to [last session / initial eval], [specific measurable change]. Barriers to progress: [pain, cognition, motivation, precautions]. Skilled OT required to [clinical reasoning for continued treatment]. Patient is making [good / fair / minimal] progress toward STG [#] and LTG [#].
Plan: Continue OT [frequency] x [duration]. Next session: [specific activities or goals to address]. Equipment recommendations: [list]. Caregiver/patient education: [topic]. Reassess [measure] in [timeframe]. Anticipated discharge: [date or criteria].

6 OT SOAP Note Examples

Each example below is based on a realistic patient scenario. Adapt the language, measurements, and goals to fit your own caseload. Notice that every note includes specific numbers (degrees, percentages, assist levels, reps) — this is what separates a note that gets approved from one that gets flagged for review.

The first four examples use the standard SOAP format. Example 5 uses the DAP format to show how mental health OT notes differ. Example 6 returns to SOAP for a burn rehab scenario.

Example 1: Outpatient Adult — Rotator Cuff Repair

This patient is a 52-year-old female, 4 weeks post right rotator cuff repair. She is an outpatient OT referral for UE ROM, strengthening, and return to ADLs.

Outpatient OT — Rotator Cuff Repair (Visit 6 of 18)

Subjective: Patient reports, "I still can't reach the top shelf or hook my bra in the back. The pain is better than last week though." Pain at rest: 2/10. Pain with overhead reaching: 6/10. She has been doing her home exercise program daily.
Objective: Dx: Right rotator cuff repair (S46.011A). Session: 45 min, outpatient clinic. Right shoulder AROM: flexion 110° (was 95° last visit), abduction 95° (was 80°), IR 45°, ER 30°. PROM: flexion 140°, abduction 125°. Strength: shoulder flexion 3+/5, abduction 3/5, IR 3/5, ER 2+/5. Patient practiced donning pullover shirt using affected arm — completed in 3 min 20 sec with 2 verbal cues for sequencing. Practiced reaching to a 48-inch shelf to retrieve a cup — reached 44 inches before pain limited further motion. Scar tissue mobilization performed to surgical incision site for 5 minutes. Therapeutic exercise: dowel-assisted flexion x 15 reps, wall walks x 10 reps, towel IR stretch x 5 reps.
Assessment: Patient demonstrates improved AROM in flexion (+15°) and abduction (+15°) compared to last session. ER remains limited and is the primary barrier to self-care tasks such as bra fastening and hair washing. Pain is trending down. Skilled OT required to progress ROM within surgical precautions, grade functional task demands, and train compensatory dressing techniques. Patient is making good progress toward STG 1 (AROM flexion ≥ 120°) and fair progress toward LTG 2 (independent overhead reaching for light objects).
Plan: Continue OT 2x/week for 6 more weeks. Next session: introduce light resistance band ER at 0° abduction, practice bra fastening with adaptive hook, and progress wall walks to corner stretch. Update home exercise program with ER stretch. Reassess AROM and dressing independence at visit 9.

Example 2: Acute Care — Hip Fracture

This patient is an 84-year-old male admitted after a right hip fracture (ORIF). OT was consulted for bed mobility, transfers, and basic ADL training on post-op day 2.

Acute Care OT — Hip Fracture (Post-Op Day 2)

Subjective: Patient states, "I just want to be able to get to the bathroom by myself. My wife can't lift me." He reports pain at 5/10 with movement, well-controlled with oral medication. Prior level of function: independent in all ADLs and IADLs, no assistive devices, lives with wife in a single-story home.
Objective: Dx: Right intertrochanteric hip fracture s/p ORIF (S72.101A). Session: 30 min, bedside. Precautions: posterior hip — no flexion > 90°, no IR, no adduction past midline. Bed mobility: supine to sit — moderate assist (50%) with verbal cues for log-roll technique. Sit to stand: moderate assist using front-wheeled walker, patient needed trunk stabilization and 2 verbal cues to avoid hip flexion > 90°. Transfer bed to bedside commode: moderate assist x 1. Seated grooming (face wash, teeth brushing): supervision only, patient completed in 6 minutes with set-up assist for supplies. Standing tolerance: 45 seconds before requesting to sit due to fatigue. UE strength: grossly 4/5 bilateral. Cognition: alert and oriented x 4, followed multi-step commands without error.
Assessment: Patient demonstrates good cognitive function and strong motivation for discharge home. He requires moderate assist for all mobility tasks on post-op day 2, which is expected. Primary barriers: pain-limited standing tolerance, unfamiliarity with hip precautions, and deconditioning. Skilled OT required to train safe transfer technique within posterior hip precautions, grade ADL tasks, and train patient and wife in caregiver strategies. Patient is a good candidate for inpatient rehab if functional gains plateau in acute care.
Plan: Continue OT daily during acute care stay. Next session: progress transfers to stand-pivot with min assist goal, begin lower body dressing training with adaptive equipment (reacher, sock aid, long-handled shoe horn). Order raised toilet seat and bedside commode for home. Coordinate with PT for gait and stair training. Family training with wife scheduled for tomorrow afternoon.

Example 3: Inpatient Rehab — Stroke (CVA)

This patient is a 62-year-old male with left hemiparesis following a right MCA stroke. He was transferred to inpatient rehab on day 5 post-onset. The session focuses on self-care tasks and upper extremity function.

Inpatient Rehab OT — Right MCA Stroke (Day 8 Post-Onset)

Subjective: Patient reports, "My left arm feels heavy. I can't button my shirt or brush my teeth with it." He reports no pain in the left UE. His wife adds, "He keeps forgetting to check his left side." Patient denies any visual complaints.
Objective: Dx: Right MCA ischemic stroke with left hemiparesis (I63.511). Session: 60 min, rehab gym and ADL suite. Left UE AROM: shoulder flexion 75°, elbow flexion/extension 100°/−15°, wrist extension 10°, grip 8 lbs (dynamometer). Right UE AROM: WFL, grip 62 lbs. FIM scores: upper body dressing 3 (moderate assist), grooming 4 (min assist), bathing 2 (max assist), feeding 5 (supervision). Left UE neglect: missed 4 of 10 targets on left side during cancellation task. Grooming task: patient brushed teeth using right hand — completed independently but missed left side of mouth; required 3 tactile cues to scan left. Dressing task: patient attempted button-down shirt — unable to manipulate buttons with left hand, completed with right hand using one-handed technique after 2 demonstrations. Therapist performed NMES to left wrist extensors x 10 min to facilitate active extension during grasp-release activity (tennis ball to cup). Patient achieved 5/10 successful releases.
Assessment: Patient demonstrates moderate left UE hemiparesis with emerging voluntary movement at the wrist. Left-sided neglect is impacting self-care safety and efficiency. FIM dressing score improved from 2 to 3 since admission. Patient is a good learner and responds well to tactile cueing for neglect. Skilled OT required to advance left UE motor recovery through NMES and task-specific training, train compensatory one-handed techniques for self-care, and address left neglect through scanning strategies. Patient is making fair progress toward STG 1 (grooming with supervision) and LTG 1 (upper body dressing with min assist using both hands).
Plan: Continue OT 5x/week per inpatient rehab schedule. Next session: introduce mirror therapy for left UE, practice one-handed button board, and begin left-side scanning strategy during meal set-up. Progress NMES to active-assisted grasp tasks. Reassess FIM self-care scores at weekly team conference. Family training for cueing strategies scheduled Friday. Target discharge to home with home health OT in approximately 10 days.

Example 4: Outpatient Hand Therapy — Carpal Tunnel Release

Hand therapy notes are some of the most measurement-heavy in OT. Payers and surgeons both expect specific grip and pinch strength values, circumferential or volumetric edema readings, and AROM in degrees for every joint tested. This example shows how to pack that data into the Objective section without making the note unreadable.

This patient is a 38-year-old office worker, 3 weeks post right carpal tunnel release. The session focuses on scar management, grip strength, and return to work tasks.

Outpatient Hand Therapy — Carpal Tunnel Release (Visit 4 of 12)

Subjective: Patient reports, "The numbness is a lot better but my hand gets tired after about 20 minutes of typing. I need to get back to work full duty next month." Pain at scar site: 3/10 with pressure. Tingling in digits 2–3 has decreased from constant to occasional. She has been doing tendon gliding exercises 3x/day as instructed.
Objective: Dx: Right carpal tunnel release (G56.01). Session: 45 min, outpatient hand therapy clinic. Incision: well-healed, no signs of infection. Scar: firm, mildly adherent, blanches with pressure. Scar mobilization performed x 8 min in all directions. Edema: right hand circumference at MCP level 19.5 cm (left 18.8 cm). AROM: wrist flexion 55° (was 45°), extension 50° (was 40°), radial deviation 15°, ulnar deviation 25°. Grip strength (Jamar, position 2): right 32 lbs (was 24 lbs), left 58 lbs. Lateral pinch: right 8 lbs, left 14 lbs. Semmes-Weinstein monofilament: digits 1–3 now detect 3.61 (diminished light touch, improved from 4.31 at visit 2). Functional task: patient typed a 200-word paragraph on standard keyboard — completed in 4 min 50 sec with 3 rest breaks for hand fatigue. Mouse use: patient clicked and dragged icons for 5 min — reports mild ache at thenar eminence. Desensitization: textured cloth rubbing over scar x 5 min, tolerated with mild discomfort.
Assessment: Patient demonstrates improved grip strength (+8 lbs) and wrist AROM (+10° flexion, +10° extension) since last visit. Sensation is recovering as expected. Scar adherence and residual edema are limiting full grip and fine motor endurance. Typing endurance of 20 minutes is below her work demand of 6+ hours. Skilled OT required for scar management, progressive strengthening, and work-simulation grading. Patient is making good progress toward STG 1 (grip ≥ 40 lbs) and fair progress toward LTG 1 (full-duty typing for 60 min without rest breaks).
Plan: Continue OT 2x/week for 4 more weeks. Next session: introduce theraputty graded resistance exercises (yellow → red), begin ergonomic workstation assessment with keyboard tray and wrist rest, and increase typing simulation to 10-min sustained trial. Continue scar mobilization and desensitization. Home program: add silicone scar pad overnight, continue tendon glides, add grip ball 3x10 reps. Discuss modified duty return-to-work letter with employer if grip reaches 40 lbs by visit 6.

Example 5: Mental Health OT — Inpatient Psychiatry

This patient is a 29-year-old female on an inpatient psychiatric unit following a crisis admission. OT is addressing daily routine, ADL participation, and community reintegration. Note: this setting uses the DAP format (Data, Assessment, Plan) instead of SOAP because many behavioral health facilities prefer the shorter structure.

Inpatient Psychiatry OT — DAP Note (Day 4 of Admission)

Data: Dx: Major depressive disorder, recurrent, severe (F33.2). Session: 45 min, unit activity room and patient room. Patient attended morning ADL routine group. She arrived 5 minutes late after 1 verbal prompt from nursing staff. She was dressed in hospital gown; hair unbrushed. During the group, therapist provided step-by-step verbal cues for morning hygiene sequence (wash face, brush teeth, comb hair, change into clean clothes). Patient completed all steps in 18 minutes with 4 verbal prompts. She made eye contact twice and responded to direct questions with 1–3 word answers. Affect: flat. In the second half of the session, patient participated in a meal-planning activity for discharge. She identified 3 simple meals she could prepare at home. She engaged more during this task, offering 2 unsolicited comments about recipes she used to cook. Patient denied suicidal ideation when asked directly. She identified one coping strategy (calling her sister) if she feels overwhelmed after discharge.
Assessment: Patient demonstrates improved ADL initiation compared to day 2, when she refused to leave her room. She required fewer prompts today (4 vs 7) to complete her morning routine. Flat affect and social withdrawal remain significant barriers to community reintegration. Her engagement during the meal-planning task suggests that familiar, meaningful activities increase her participation. Skilled OT required to grade activity demands, build daily routine structure, and develop a discharge safety plan that includes ADL and IADL supports. Patient is making fair progress toward goal 1 (complete morning ADL routine with ≤ 2 prompts).
Plan: Continue OT daily during inpatient stay. Next session: co-create a written morning routine checklist for the patient to follow independently, introduce a simple cooking task (sandwich prep) to build IADL confidence, and practice identifying 2 additional coping strategies. Coordinate with social work on discharge housing and outpatient OT referral. Discuss community resources for day programming at team meeting Thursday.

Example 6: Burns / Wound Care

Burn rehab documentation needs to track several things at once: wound healing status, edema trends, ROM changes, splint wearing schedules, and pain during stretching. A well-written note shows the wound care team, the surgeon, and the payer exactly where the patient stands across all of these areas.

This patient is a 45-year-old male with second-degree burns to bilateral hands sustained in a workplace accident. OT is addressing ROM, edema management, splint compliance, and functional hand use.

Burn Rehab OT — Bilateral Hand Burns (Week 3 Post-Injury)

Subjective: Patient reports, "My hands feel stiff and tight, especially in the morning. The splints are uncomfortable but I've been wearing them at night like you said." Pain at rest: 3/10. Pain during stretching: 7/10. He reports difficulty holding a fork and opening bottles. He has been performing home exercises but admits he skips the afternoon set when the pain is high.
Objective: Dx: Second-degree burns to bilateral hands, dorsal surfaces (T23.201A). Session: 50 min, outpatient burn rehab clinic. Wound status: both hands — partial thickness burns healing well, no signs of infection, new epithelium forming over dorsal MCP joints. Compression gloves worn during session. Edema (volumetric): right hand 385 mL (was 410 mL), left hand 370 mL (was 395 mL). Bilateral AROM: MCP flexion R 60° / L 65° (was 50° / 55°), PIP flexion R 75° / L 80°, composite fist — fingertips reach 2 cm from palmar crease bilaterally (was 3 cm). Grip strength (Jamar, position 2): R 22 lbs, L 20 lbs (pre-injury baseline reported as 85 lbs R, 80 lbs L). Splint check: bilateral dorsal anti-deformity splints — skin intact under straps, no pressure areas, patient demonstrates correct don/doff technique. Functional task: patient attempted to hold and use a fork with built-up handle — completed 8 of 10 pick-up trials with modified grasp. Patient attempted to open a twist-cap bottle — unable due to pain and limited composite fist. Retrograde massage to bilateral hands x 5 min each. Sustained passive stretch to MCP and PIP joints x 10 min. Active exercise: tendon gliding, isolated finger extension, and thumb opposition x 3 sets of 10.
Assessment: Patient demonstrates improved edema (−25 mL right, −25 mL left) and AROM (+10° MCP flexion bilaterally) compared to last visit. Scar formation is beginning at the dorsal MCP joints and will likely limit extension if not managed proactively. Grip strength remains significantly below baseline at roughly 25%. Splint compliance is good at night but stretching compliance is inconsistent in the afternoon. Skilled OT required to manage scar formation, progress ROM through graded stretching and functional tasks, and modify ADL tools to maintain independence during recovery. Patient is making fair progress toward STG 1 (composite fist — fingertips to palmar crease) and minimal progress toward LTG 1 (grip ≥ 50 lbs bilaterally).
Plan: Continue OT 3x/week. Next session: begin silicone gel sheeting to dorsal MCP scars, introduce paraffin wax dip prior to stretching to reduce pain and improve tissue extensibility, and trial a universal cuff for utensil use. Progress grip strengthening to theraputty (tan) for sustained grasp activities. Adjust home program: move afternoon exercises to after a warm shower when tissue is most pliable. Reassess edema and AROM in 1 week. Discuss with physician adding a compression garment fitting at week 5.

How to Write an OT SOAP Note Faster

Writing detailed SOAP notes takes time, especially when you are seeing 8–10 patients a day. Here are four ways to speed things up without losing quality:

1Start with a template. Copy the blank template above and pre-fill the parts that stay the same — diagnosis, precautions, session duration. Then you only need to fill in what changed today.
2Be specific with measurements. Vague phrases like "ROM improved" take just as long to type as "shoulder flexion 110° (was 95°)" — but the second version is more useful and less likely to trigger an audit.
3Document skilled reasoning in the Assessment. Payers want to know why only an OT can do what you did. One sentence — "Skilled OT required to grade task demands within posterior hip precautions" — can make the difference between approval and denial.
4Use an AI scribe. An ambient AI scribe like Augustun for occupational therapy listens to your session and drafts a structured SOAP note in seconds. You review it, sign it, and move on. That can save 10–15 minutes per note.

One more tip: write your Assessment section first. It forces you to think about what actually matters in the session — what changed, what barrier you addressed, and why skilled OT was needed. Once the Assessment is done, the Subjective, Objective, and Plan sections almost write themselves.

If your facility uses an EHR with built-in templates, customize the default fields to match your most common diagnoses. For example, a hand therapy template might include grip strength, pinch strength, edema measurements, and scar status as standard fields, while an inpatient rehab template might default to FIM scores and assist levels. The less you have to type from scratch, the faster your notes get done.

Let an AI Scribe Handle the Note

Augustun is an ambient AI medical scribe built for clinicians. It listens during the visit, then writes a complete, structured note in seconds — SOAP, DAP, or BIRP formats — so you can stay focused on the patient instead of the keyboard. It also suggests ICD-10 and CPT coding, drafts treatment plans and patient instructions, and pushes finished notes into 400+ EHRs through a simple browser extension.

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Augustun drafts your OT SOAP note while you treat. Review, sign, and move on. Try it free at [augustun.com](/) or see how it fits OT workflows at [Augustun for occupational therapy](/specialties/occupational-therapy).

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Final Thoughts

Good OT SOAP notes do not need to be long. They need to be clear, specific, and connected to your patient's goals. Every note should answer three questions: what happened today, why it matters clinically, and what you are going to do about it next time.

Pick the example above that is closest to your setting, swap in your patient's details, and make sure every section includes the numbers, assist levels, and skilled reasoning that payers look for. If you want to skip the typing altogether, let Augustun draft the note while you focus on what you do best — helping people get back to their everyday lives.

Frequently asked questions

What is the SOAP format in occupational therapy?

SOAP stands for Subjective, Objective, Assessment, and Plan. The Subjective section captures what the patient or caregiver says. The Objective section records measurable findings like ROM, strength, and assist levels. The Assessment section explains your clinical reasoning and whether the patient is progressing. The Plan section outlines next steps, frequency, and goals. It is the most widely used format for OT daily notes across outpatient, acute care, inpatient rehab, and home health settings.

How long should an OT SOAP note be?

There is no set word count. A good OT SOAP note is long enough to show skilled care and measurable progress, but short enough to be read quickly. Most daily SOAP notes run between half a page and one full page. Focus on specific measurements, assist levels, and clinical reasoning rather than long narrative descriptions. If your note is routinely longer than one page, consider whether every detail is necessary for reimbursement and continuity of care.

What is the difference between SOAP and DAP notes in OT?

SOAP has four sections — Subjective, Objective, Assessment, and Plan. DAP has three — Data, Assessment, and Plan. In DAP, the Data section combines what the patient reports and what the therapist observes into one block, which makes the note shorter. SOAP is more common in medical settings like hospitals and outpatient clinics because payers prefer the clear separation of subjective and objective data. DAP is popular in school-based OT and mental health OT where sessions are shorter and documentation is more narrative.

Can occupational therapy assistants (COTAs) write SOAP notes?

Yes. In most states, COTAs can write daily SOAP notes for treatment sessions they provide. However, the supervising OTR/L must co-sign the note and is ultimately responsible for the content. COTAs typically cannot write initial evaluations or discharge summaries — those require the OTR/L. Always check your state practice act and facility policy for specific co-signature and supervision requirements.

Can an AI scribe write OT SOAP notes?

Yes. An ambient AI scribe such as Augustun listens during the session and drafts a structured SOAP, DAP, or BIRP note for you to review and sign. It captures patient quotes, measurements, and clinical reasoning from your conversation, then formats everything into the correct sections. The therapist always reviews and approves the note before it goes into the chart. Augustun is HIPAA- and GDPR-compliant, recordings are never stored, and finished notes sync to 400+ EHRs through a browser extension.