Occupational Therapy Daily Treatment Note (SOAP)

Date of Service: [Date of service]

Setting: [outpatient / inpatient / SNF / home health / school-based / telehealth]

Therapist: [Therapist name and credentials]

Mode: [individual / group / concurrent / co-treatment]

Precautions: [Relevant precautions] (Include only if clinically relevant; otherwise omit this field.)

Subjective

[Client self-reported status since last session, including changes in function, symptoms, tolerance, or participation; falls or near-falls; new medical events; pain if relevant with location, rating, and functional impact; home program adherence with benefits or barriers; client priorities for today's session] (1–4 sentences. If client cannot report, document reason and alternate source. If session missed or abbreviated, document reason per policy.)

Objective

Observations: [Functional performance in targeted occupations/ADLs with standardized assistance levels and assist type; cueing required with frequency and purpose; task parameters as relevant; UE/hand metrics or cognitive observations only when directly relevant to today's session]

Interventions: [For each skilled intervention: intervention type, goal targeted, task/activity performed, key parameters, skilled OT actions applied, and client performance/response including assistance needed, tolerance, and carryover. Include education topic, learner, method, and demonstrated understanding if training provided. Include device, adjustments, training, and wear schedule if orthotic management performed.]

Time: [Total timed minutes] timed; [Total treatment time] total (If billing multiple timed codes, briefly list intervention labels with minutes.)

Assessment

[Clinical interpretation of today's findings and functional significance; client response to intervention including tolerance, carryover, and barriers; goal status with trend and measurable anchor for each goal addressed; statement of why skilled OT remains indicated or if discharge criteria being met; if progress lacking, contributing factors and planned adjustments]

Plan

Next Visit: [Focus areas and goals targeted; planned progression or regression of task demands, cues, or environment; any planned reassessments]

Home Program: [Activities/strategies for client/caregiver; frequency; precautions; equipment needed; how understanding was confirmed or will be reinforced]

Coordination: [Team communication, DME orders, caregiver training scheduling, or frequency/duration changes with rationale] (Include only if relevant; otherwise omit.)

Signature

Signature/Credentials: [Therapist signature and credentials]

Date/Time Signed: [Date and time]

(Include co-signature, supervisory attestation, or other contributors only when required by payer, regulation, or facility policy.)