An effective progress note is essential to tracking the progress of an occupational therapy patient's case. One of the most effective forms of progress notes is the "soap" note. Soap notes effectively record the subjective, objective, assessment and plan. Soap note taking is an organised way to include all of the relevant information that needs to be recorded after a visit or appointment with a patient.
Record the subjective in the first paragraph of your note. The subjective should include the presenting problem or condition. For example: "The patient presented with a knee that is recovering post-surgery. The patient states that the pain level is at a 5 on a scale of 10."
Record the objective in the second paragraph. The objective should include your observations as a therapist. For example: "This therapist observed a marked swelling of the affected knee, which appears to be fluid build-up. The skin is of normal colour, and there is no sign of infection."
Record the assessment in the third paragraph. The assessment should include the diagnosis, or your professional theory on the condition creating a problem. For example: "The patient is suffering from fluid on the knee, which is creating a mild level of pain."
Record the plan in the final paragraph. The plan is the description of treatment or services that will be performed for the condition that was stated in the assessment. For example: "Therapist will continue therapy with this patient as scheduled and monitor knee fluid for possible draining."
Things you need