SOAP Notes

Amy Shissler
My Cerebellar Stroke Recovery

June 7, 2013

SOAP notes are what physical and occupational therapists call their daily notes.  I don’t know if that’s what speech therapists call their notes.  Every time you have a PT or OT appointment, the therapist will write a SOAP note.  I don’t know if this information can be helpful in any way but here ya go.  SOAP is an acronym for subjective, objective, assessment, plan.  The subjective is whatever you say.  So if I go into my OT appointment and say “I’m still writing really crappy,”  she’ll write on her note “patient reports she is still writing crappy.”  She’ll use the word ‘crappy.’  It’s whatever the patient says.  I remember one time I wrote patient reports “I feel like Superman.”  That boosted my ego a bit.  Objective means whatever you did during the session.  So when I’m in OT and put the pennies in the piggy bank 3 times, she’ll write that down – that I did that 3 times.  It’s whatever you do during the session.  Assessment is weird.  It’s supposed to be how the patient did during the session but often it ends up being objective.  A good assessment would be “due to decreased strength, the patient had trouble standing up today.”  This is an assessment of the situation.  Much better than “the patient had trouble standing up today.”  That’s objective.  Then plan is what you plan on doing next session.  If you plan on adding an exercise, you write “add leg press” or whatever.  If you plan on doing a re-evaluation, the therapist would write “do re-eval.”  Ok that’s SOAP notes for you.

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My Cerebellar Stroke Recovery