SOAP notes for occupational therapy, with examples

Occupational therapy notes have a harder job than most. They need to record what you did, but also why it matters to the person's daily life, what you saw in their home, and how the session moves them towards goals that a plan manager, a support coordinator or an NDIA planner may read months later. A note that says “Session completed, client engaged well” records attendance. It does not record therapy.

SOAP gives the note a structure that holds up: Subjective, Objective, Assessment, Plan. Here is how each section works for OT specifically, a worked example, and the habits that make notes easy to turn into reports.

S: Subjective, in the client's own words

Record what the client, family or carer tells you: how they have managed since the last session, what has got harder or easier, and what matters to them this week. Use their words where the words carry meaning. “I can't get out of the shower without hanging on to the towel rail” tells the next reader far more than “reports difficulty with transfers”.

• Daily routines and roles: self-care, household tasks, work, study and community
• Changes since the last session, good or bad
• Carer or family observations, attributed to the person who made them
• The client's own priority for this session

Include the people around the client. A carer mentioning that the morning routine now takes twice as long is subjective data, and it is often the first sign that something has changed.

O: Objective, what you observed and measured

This is where OT notes earn their keep, because so much of the work happens in the client's real environment. Record what you saw, not what you concluded:

• Task performance. What the client did, with what level of assistance and how long it took. “Sit to stand from bed with standby assistance, three attempts, using bed rail.”
• Home environment. Steps, rails, floor surfaces, bathroom layout, lighting, clutter and trip hazards, with measurements where equipment or modifications are being considered.
• Equipment. What is in place, whether it is used, whether it is used safely, and its condition.
• Standardised measures. Results from any assessment your practice uses, with the score and the date.
• Cognition and safety. Attention, sequencing, insight and judgement during tasks, described as behaviour rather than as a label.

A: Assessment, your clinical reasoning

The assessment connects the subjective and the objective to meaning. What do today's observations tell you about function, risk and progress? Is the client improving, plateauing or declining, and why? For NDIS participants, name the plan goal this session addressed and whether the evidence shows progress towards it.

Be specific enough that someone else could pick up the case tomorrow. “Transfers improving: standby assistance today compared with minimal assistance two weeks ago. Bathroom remains the highest falls risk because there is no grab rail at the shower entry” gives the next clinician, and the next report, something solid to work with.

P: Plan, what happens next

Record the next steps: interventions planned, equipment to trial or order, home modification recommendations, referrals, education given and what the client or carer will practise before next time. Note the next review date, and anything that needs a quote, a report or a conversation with the support coordinator.

A worked example

Here is a hypothetical home visit note for an NDIS participant working towards showering independently. The details are invented; the structure is the point.

• S: Client reports showering twice this week with partner present, “still scared of slipping on the way out”. Partner reports client now dries and dresses seated without help. Client's priority: to shower without partner in the bathroom.
• O: Step-over shower hob, approx. 15 cm. Transfer in completed with standby assistance, using the vanity edge for support; transfer out with minimal assistance, hesitant. Seated drying and dressing on shower stool completed independently in 12 minutes. Floor tiles wet and slippery after showering; no non-slip mat in place.
• A: Progress towards NDIS goal “to shower independently at home”: drying and dressing achieved; transfers remain the barrier, with fear of falling contributing. Use of the vanity for support is a falls risk. Grab rail at shower entry and a non-slip floor surface are likely to enable progression from standby assistance to independent transfers.
• P: Recommend grab rail at shower entry; written specification to partner and support coordinator this week. Trial non-slip mat. Partner to supervise transfer practice three times before next visit using the sequence taught today. Review in two weeks. Note progress for the report ahead of the plan reassessment.

Habits that make OT notes easy to report from

• Write the note on the day, ideally before the next visit, while the details of the environment are fresh.
• Use the same goal wording as the participant's plan, so a progress report can be assembled from notes rather than reconstructed from memory.
• Keep observation and interpretation apart: what you saw goes in O, what it means goes in A.
• Record measurements, and photos with consent, whenever equipment or modifications are being recommended.
• Complete and lock the note once it is finished. Corrections should be new versions, not quiet edits.

If your practice also has physiotherapists, the same principles apply with a different emphasis. Our guide to SOAP notes for physiotherapy walks through that version.

Writing OT notes in AspireOS

Progress notes in AspireOS are built from templates, including SOAP, initial, review, discharge and your own, so an OT template can carry prompts for environment, equipment and plan goals. Clinicians can dictate into a note field where the browser supports it, or type or paste a quick summary, and AspireAi's AI note sorts the words under the practice's note headings as a draft for the clinician to review and edit before completing the note. Notes keep a version history and are completed and locked, and when a plan reassessment comes round, AspireAi can build a progress report from completed notes for the clinician to check. The features page lists the full clinical toolset.

You can start free, set up an OT note template and write your first notes in it the same day.