SOAP Note Example
Occupational Therapy SOAP Note Example
Below is a complete SOAP note example for an occupational therapy session treating a stroke survivor focused on upper extremity function and return to independence with activities of daily living. This example demonstrates proper documentation of standardized assessments, functional performance measures, and skilled intervention planning.
Complete Occupational Therapy Note
SUBJECTIVE:
Patient is a 63-year-old right-hand-dominant male, 5 weeks status post left middle cerebral artery ischemic stroke (01/24/2026), resulting in right-sided hemiparesis. This is visit 14 of 30 authorized outpatient occupational therapy sessions. Patient reports that right hand function has been "slowly coming back but I still can't do the things I used to do without thinking." States he is now able to stabilize a bread bag with his right hand while his left hand opens it, which he could not do 2 weeks ago. Primary frustrations: difficulty buttoning shirts (wife assists every morning), inability to write legibly (formerly right-hand dominant writer), and trouble managing utensils during meals — reports he has switched to using a built-up handled spoon in his left hand for most meals but "wants to get back to using a fork and knife normally." Reports mild right shoulder pain rated 2/10 at rest, increasing to 4/10 with overhead reaching, no pain at night. Denies numbness or tingling in right upper extremity — sensation has been "about the same" since last visit. Home exercise program compliance: performing prescribed exercises daily with wife's assistance, approximately 30 minutes each morning. Patient's stated goals: return to independent dressing including buttons and zippers, resume eating with standard utensils using right hand, return to writing checks and signing documents, and resume his hobby of woodworking in his garage workshop. Prior level of function: fully independent in all ADLs and IADLs, retired mechanical engineer, active in community woodworking club.
OBJECTIVE:
Canadian Occupational Performance Measure (COPM) — reassessment (initial administered at evaluation visit 1): Performance scores (1-10 scale): buttoning shirt 3 (initial 1), eating with standard utensils 2 (initial 1), writing/signing name 2 (initial 1), using hand tools for woodworking 1 (initial 1). Satisfaction scores (1-10 scale): buttoning shirt 2 (initial 1), eating with standard utensils 2 (initial 1), writing/signing name 1 (initial 1), using hand tools 1 (initial 1). Mean performance score change: +1.0 (clinically significant change is 2.0 or greater). Functional Independence Measure (FIM) — selected self-care items (7-point scale): eating 4 (minimal assistance — requires setup and adaptive utensil), grooming 5 (supervision — completes with verbal cues for sequencing), upper body dressing 3 (moderate assistance — unable to manage buttons, requires help with right sleeve), bathing 4 (minimal assistance — needs help washing left side of body and managing faucet controls). Right upper extremity assessment: active ROM (goniometry) — shoulder flexion 95 degrees (left 170 degrees), shoulder abduction 88 degrees (left 175 degrees), elbow flexion 130 degrees (left 145 degrees), elbow extension -8 degrees (left 0 degrees), wrist extension 20 degrees (left 65 degrees), wrist flexion 35 degrees (left 75 degrees). Grip strength (Jamar dynamometer, position 2, best of 3 trials): right 18 lbs (left 85 lbs; pre-stroke estimated normative for age/gender approximately 80-90 lbs right dominant). Lateral pinch: right 5 lbs (left 16 lbs). Three-jaw chuck pinch: right 4 lbs (left 14 lbs). Tip pinch: right 2 lbs (left 10 lbs). Modified Ashworth Scale: right elbow flexors 1+ (slight increase in tone with catch at mid-range), right wrist flexors 1 (slight increase in tone at end range), right finger flexors 1 (slight increase at end range). Sensation: light touch — intact throughout right upper extremity; proprioception — impaired at right wrist (3/5 correct position identification) and right fingers (2/5 correct), intact at elbow and shoulder; stereognosis — unable to identify 2 of 5 common objects (key, coin) placed in right hand without vision. Fine motor assessment: Nine-Hole Peg Test — right hand 98 seconds with 2 dropped pegs (left hand 22 seconds; normative for age 22-25 seconds); able to pick up 1-inch pegs with lateral prehension pattern, difficulty releasing pegs into holes due to impaired finger extension timing. Functional task observation: attempted buttoning a practice shirt with large buttons (3/4 inch) — completed 2 of 5 buttons in 4 minutes with significant compensatory trunk flexion and verbal cuing; standard shirt buttons (1/2 inch) — unable to complete. Writing sample: printed first name in 45 seconds, letters oversized and irregular, unable to maintain consistent baseline, grip pressure excessive with tremor noted. Treatment provided this session (55 minutes): neuromuscular electrical stimulation (NMES) to right wrist and finger extensors — 15 minutes during active-assisted reach and grasp tasks with various sized objects (cylinders, cones, pegs); task-specific training for buttoning using graded button board (large to small) with verbal and tactile cuing for finger placement and bilateral coordination — 15 minutes; therapeutic exercise for right upper extremity strengthening including resistive putty gripping and pinching (medium resistance), wrist extension with 1 lb weight (3 sets of 10), and shoulder flexion with dowel rod (bilateral assisted, 3 sets of 10) — 10 minutes; handwriting retraining using wide-lined paper and built-up pen, practicing letter formation with focus on controlled pressure and baseline tracking — 10 minutes; home exercise program review and progression — 5 minutes.
ASSESSMENT:
Patient is 5 weeks post left MCA stroke with right hemiparesis, demonstrating slow but measurable gains in right upper extremity function. COPM performance scores show a mean improvement of 1.0 points, which approaches but has not yet reached the clinically significant threshold of 2.0 — however, the trend is positive and consistent with the expected recovery trajectory at this stage. FIM scores reflect continued need for assistance with self-care tasks, particularly upper body dressing (FIM 3, moderate assist) and eating (FIM 4, minimal assist with adaptive equipment). Grip strength at 18 lbs represents approximately 21% of estimated pre-stroke capacity, and pinch strength deficits are proportionally more severe — tip pinch at 2 lbs is the most impaired and directly limits fine motor tasks like buttoning and writing. The Nine-Hole Peg Test time of 98 seconds with dropped pegs indicates significant fine motor coordination impairment but is improved from the initial evaluation where the patient was unable to complete the test. Proprioceptive deficits at the wrist and fingers and impaired stereognosis are contributing to the difficulty with manipulation tasks and will require targeted sensory re-education. Mild spasticity (Modified Ashworth 1 to 1+) is manageable and not yet limiting functional recovery. Patient is motivated, compliant with his home program, and demonstrating neuroplastic recovery potential as evidenced by his ability to now use the right hand as a functional stabilizer — a task he could not perform 2 weeks ago. Continued skilled occupational therapy is indicated to progress neuromuscular re-education, advance fine motor coordination, retrain ADL skills, and provide adaptive strategy training to maximize functional independence during the recovery window.
PLAN:
Continue outpatient occupational therapy 3x/week for the next 4 weeks, then reassess for frequency adjustment. Short-term goals (4 weeks): increase grip strength to 30 lbs, complete buttoning of large buttons independently within 2 minutes, achieve FIM score of 5 (supervision) for upper body dressing, complete Nine-Hole Peg Test in under 60 seconds without dropped pegs, and improve proprioceptive accuracy at the wrist to 4/5 correct. Treatment progression: advance NMES protocols to include functional grasp-release tasks with smaller objects (coins, cards, pegs under 1/2 inch); introduce constraint-induced movement principles during clinic sessions — 30 minutes of forced-use right hand tasks with left hand resting; begin sensory re-education program targeting stereognosis (texture identification, object recognition with vision occluded, 10 minutes per session); progress buttoning practice to standard-size buttons with fading cues; introduce modified independence strategies for dressing as interim solution (button hook, elastic shoelaces, magnetic closures on preferred shirts) while continuing to work toward unassisted buttoning. Home exercise program updated: add therapy putty exercises for finger extension (flatten and spread putty, 3 sets of 10, 2x daily), coin manipulation practice (pick up, flip, and place 10 coins, 2x daily), and writing practice on wide-lined paper (10 minutes daily, focusing on first and last name and common words). Reassess COPM, grip and pinch strength, Nine-Hole Peg Test, and FIM self-care items at visit 22. Coordinate with speech-language pathology regarding reported word-finding difficulties during complex conversation — patient mentioned this incidentally today and it warrants screening. Communicate with PCP Dr. Hoffman regarding shoulder pain if it exceeds 4/10 or limits therapy participation — may require imaging to rule out rotator cuff involvement secondary to subluxation risk.
Section-by-Section Breakdown
What to include in each section and why it matters.
Subjective
In occupational therapy SOAP notes, the subjective section should capture the patient's self-reported functional status in their own words, focusing on specific activities of daily living they can and cannot perform. Document the patient's stated goals using their language — these should reflect meaningful occupations, not just impairments. Include the mechanism and date of onset, current visit number, and home exercise program compliance because these establish the clinical timeline and demonstrate patient engagement. Note the prior level of function and the patient's valued roles and activities (woodworking, writing checks) because occupational therapy is fundamentally about restoring participation in meaningful occupations, and this context drives the entire treatment plan.
Objective
Occupational therapy documentation requires standardized, occupation-focused outcome measures alongside impairment-level data. The COPM captures the patient's own priorities and tracks both performance and satisfaction — always compare to baseline scores and note whether the change is clinically significant. FIM scores provide a universal functional language understood across the rehabilitation team. Pair these occupation-level measures with specific impairment data: goniometry, grip and pinch strength with dynamometer readings, spasticity grading on the Modified Ashworth Scale, sensory testing results at each joint level, and standardized fine motor tests like the Nine-Hole Peg Test. Document functional task observations with the specific task attempted, the level of assistance required, compensatory strategies observed, and time to completion. Detail every intervention provided with duration, parameters, and clinical rationale.
Assessment
The occupational therapy assessment connects impairment-level findings to functional limitations in daily occupations. Interpret standardized assessment scores in context — note whether changes meet clinically significant thresholds and compare to expected recovery trajectories for the diagnosis. Identify which impairments are the primary drivers of each functional limitation (tip pinch deficit limiting buttoning, proprioceptive impairment compounding fine motor inaccuracy) because this reasoning justifies the specific interventions you have selected. Document neuroplastic recovery indicators (new functional abilities emerging) to support prognosis. Explicitly state why skilled occupational therapy is still required — insurance reviewers need to see that the patient cannot safely progress independently and that the interventions require clinical expertise.
Plan
The occupational therapy plan should include treatment frequency with reassessment timelines, measurable short-term goals tied to specific occupational outcomes (not just impairment improvements), and detailed intervention progressions. Include both restorative approaches (NMES, strengthening, sensory re-education) and adaptive or compensatory strategies (button hook, magnetic closures) to address immediate functional needs while continuing to work toward recovery. Update the home exercise program with specific activities, repetitions, and frequency. Document interdisciplinary coordination — occupational therapists frequently identify issues outside their scope during treatment (speech difficulties, pain requiring medical evaluation) and this communication demonstrates comprehensive patient-centered care.
Generate Occupational Therapy Notes with AI
Stop writing notes from scratch. Wellistic AI generates professional SOAP notes from your brief session summary.
Start Generating Notes in 30 Seconds
Join thousands of wellness practitioners saving hours on documentation every week.