Writing Occupational Therapy SOAP Notes
Occupational therapy in Chipley, FL, refers to the recovery process after a illness or injury that changed a patient's daily functioning. It's the occupational therapist's goal to ensure the patient makes progress and is restored to their original state as much as possible. In order to track this progress, many therapists use the SOAP note system. After each visit with a patient, the therapist can record the patient's current condition and mark their progress. If this is new territory to you or you need a refresher, be sure you understand what to put down for the subjective, objective, assessment, and plan paragraphs.
Subjective information goes in the first paragraph. This refers to the observations the patient gives. You ought to interview this patient to learn about old complaints as well as new ones. Ask how often the ailment occurs, where, and to what degree. You would jot down what they say, maybe saying "The patient rates the pain in his elbow at a 6 out of 10." You may also note how tired or agitated the patient may appear.
Next, write down objective info, which comes from testing and observation. Vital signs are evaluated, lab results are given, and a basic physical exam is run. Blood pressure, blood panels, mental test scores, temperature, pulse, height, and weight are typically included in this section. The patient may also give their input on objective information. Note that these observations are usually measurable.
The third paragraph is devoted to an assessment. This is where you give your diagnosis or at least your professional theory on the cause. You give an assessment after you have collected and digested the information from the first two sections of the SOAP note. Discuss the patient's current status. You may use words like resolved, stable, improved, or progressing. Know that more than one diagnosis may be included in the assessment.
After making these evaluations and coming up with a diagnosis, now is the time to devise a plan to be put into action. This should be a treatment plan to improve the condition stated in previous parts of the SOAP note. Write down proposed medicine changes. You may suggest discontinuing, starting, increasing, or decreasing certain meds. Consider running more tests, setting up referrals, and giving new instructions to the patient. Also think about follow-up care that may be necessary. Now your SOAP note for occupational therapy in Chipley, FL, ought to be complete.
Subjective
Subjective information goes in the first paragraph. This refers to the observations the patient gives. You ought to interview this patient to learn about old complaints as well as new ones. Ask how often the ailment occurs, where, and to what degree. You would jot down what they say, maybe saying "The patient rates the pain in his elbow at a 6 out of 10." You may also note how tired or agitated the patient may appear.
Objective
Next, write down objective info, which comes from testing and observation. Vital signs are evaluated, lab results are given, and a basic physical exam is run. Blood pressure, blood panels, mental test scores, temperature, pulse, height, and weight are typically included in this section. The patient may also give their input on objective information. Note that these observations are usually measurable.
Assessment
The third paragraph is devoted to an assessment. This is where you give your diagnosis or at least your professional theory on the cause. You give an assessment after you have collected and digested the information from the first two sections of the SOAP note. Discuss the patient's current status. You may use words like resolved, stable, improved, or progressing. Know that more than one diagnosis may be included in the assessment.
Plan
After making these evaluations and coming up with a diagnosis, now is the time to devise a plan to be put into action. This should be a treatment plan to improve the condition stated in previous parts of the SOAP note. Write down proposed medicine changes. You may suggest discontinuing, starting, increasing, or decreasing certain meds. Consider running more tests, setting up referrals, and giving new instructions to the patient. Also think about follow-up care that may be necessary. Now your SOAP note for occupational therapy in Chipley, FL, ought to be complete.
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