Quick Notes: Note writing in OT (SOAP)

I’m writing this quick guide since I have noticed about 1 in 4 searches coming from google are for the words "example of SOAP notes" or some other combination. So I'm happy to help. Now before I start here is a quick overview of note writing ending up with some examples.

• why?
• varieties of note writing - mental health v's everyone else..
• Common guidelines (Do's and Don'ts)
• SOAP basics
• SOAP in detail
• Subjective
• Objective
• Assessment/Analysis
• Planning
• Examples
• References

Why?

So why do OT's (and others) need to write notes? A few reasons:

1. Legal/Ethical responsibility: Necessary under COT code of ethics (3.4) (ALL records are officially the property of the Secretary of State)
2. Statistics/Audits - used to measure success of intervention & for research
3. For following progress of colleagues work

The various varieties of notes

So writing clear, concise easy-to-understand but also professional notes is essential - but do we need to write lengthy notes about everything? Well not quite - often notes will get broken down into a number of areas including telephone contact sheets for quick relevant calls, referral forms, assessment forms, reports and discharge summaries. However the large volume of notes that are scrutinised more than any other are the day-to-day client progress notes - the ones detailing actual intervention and the main port of call for any health professional. For all notes the majority of health professionals follow some form of standards for record keeping — directed by either their health authority or/and the overarching professional body. For OT in the UK this can be found in the “Standards for Practice: Occupational Therapy Record Keeping” which outlines the requirements of all records written and kept by an OT.

Some of the commonly used guidelines include that notes should:

• be legible & jargon free - check with your department as to the specific shorthand acronyms - some go as far as no acronyms so beware! (even things like TV can be "banned")
• be made within 24 hours
• be signed and dated by the author
• avoid opinion & record only facts observed. Subjective info should be identified as such
• show that you are addressing all the identified needs. Don't say you are going to do about a certain need if you can't
• not be altered, unless the error is crossed out but still readable - signed and dated
• not have tipp-ex on them
• not have lines with blank spaces on. You should put a straight line across lines to fill them. This is to stop you writing notes at a later date.
• not contain a diagnosis made by someone who is not qualified to make one - write the symptoms instead e.g. "Doris has signs & symptoms of xxx. Can medical team please assess"
• not record assumptions. for example - you shouldn't state "the patient appeared sad." Unless of course it is justified.

Note that the last two points are tricky. Let's think about the following:

"I went to see Mrs X who is suffering from an acute episode of clinical depression. She appeared low in mood and angry that she wasn't allowed off the ward today"

So how would you write this knowing the previous points? Well classically you would write:

"Meeting with Mrs X. Mrs X appeared low in mood and showed anger towards the OT that she was not allowed off the ward"

Hmm. Well lovely as that is, it's dangerous on a few grounds. Who says she is low in mood? Your view of appearing low in mood may be completely different How did she show "anger"? What did she do? Its much harder to write, but this would be better:

"Meeting with Mrs X. Mrs X reported to feel low and tearful. Discussed with OT how she is angry and confused that she is not allowed off the ward. OT discussed with her the concerns regarding her mental state and sectioning system"

SOAP Note Format

Or what is now commonly called SOAP has it's history in the POMR - Problem Orientated Medical Records system (Weed, 1971). This was drawn up to:

• improve communication among all those caring for the patient
• display the assessment, problems and plans in an organized format to facilitate the care of the patient
• use in record review and quality control

There are four commonly used components of SOAP:

S = Subjective (what the client Said - e.g. their reported feelings
O = Objective (what you Observed - e.g. what you did. NB: not your subjective interpretation)
A = Assessment (the Analysis of Subjective & Objective)
P = Plan

In detail:

Subjective

Presents the problems from the patients viewpoint — how he/she may feel. ”¨Information from other individuals also go here. Relevant info also include:

• The reason for the patients visit — often in the patients own words
• History of presenting condition/function in chronological age
• Symptoms data including severity, location, duration & frequency of symptoms the patient is experiencing
• Past medical/social history
• Medications being currently taken as well as appetite, diet and allergies

Objective

Records the physical symptoms and includes specific objective statements. Can be gathered from Observation of the patient, Physical Examination, Lab results and X-Rays for example. More than often it consists of what you observe. Note that it is this part that is often scrutinised for accuracy - don't make observations unless they wouldn't be observed the same way as someone else - e.g. X was crying and not X was sad.

Assessment/Analysis

Interpretation of the subjective/objective elements.

Plan

Describes plan for treatment/further sessions and management of the noted issues. Could include referral, phone call or plan to collect more information. Note that some people often use this as objective style plan - a client-centred, specific and measurable plan of intervention by a set time (SMART).

Note that some people will put Objective before Subjective statements - arguing that its easier to write - it doesn't matter just as long as its all in there! Its also often wise to put a little line before the SOAP just stating what the note entry is for (e.g. visit, phone call, discharge etc..)

So on with the examples. Now I'm in no way suggesting these are perfect - just examples of soap format. Remember that everybody writes notes slightly differently! Feel free to comment on them below. See the "OTA's guide to writing SOAP notes" book for far more comprehensive examples (see references below)

Example 1 - Acute Accident & Emergency

OT (Bob Smith) initial interview, mobility assessment (bed to rollator frame, walk 10m).

S. Patient reported difficulties in home care, in particular cleaning and shopping. Expressed concern of putting strain on son as a primary carer. Keen to get back to previous roles within home (mother, housewife) and visit friends.

O. Patient was polite and joking throughout. Jane required touch cues for sit -> stand and moderate physical assistance to grasp rollator frame. Stood un-aided at rollator-frame for 20 seconds. Reduced mobility and endurance seen - needing assistance after 2m.

A. Jane is at risk of further falls. Would benefit from home visit to investigate risks n home environment.

P. Refer to physiotherapy for full mobility assessment, Plan home visit with Jane this PM, Discuss with social work current/future Package of Care.

Example 2 - Paediatrics

OT (Bob Smith) visited Jenny at School to observe play and socialisation skills

S. Jenny was non-verbal throughout session. Jenny's teacher discussed with OT how Jenny had previously been listening to a story with no concerns.

O. Mary observed to stand and play in sand tray for 15 minutes. Bilateral use of upper limbs and independent in manipulating objects. Worked on her own with moving sand in a truck from one area to another. Did not interact with others when asked by another child to join their game or when OT asked Jenny if she would like to join them. Continued playing in sand when asked to stop.

A. Jenny would benefit from further observation within other classroom activities.

P. Organise visit to school during group-work time

Example 3 - Mental Health

Group cookery session

S. Jane stated that she enjoyed baking cakes at home.

O. Client was admitted 1 week ago and second cooking session attended. Participated in activity focussing well on tasks throughout and helped other less-proficient members. Unable to recognise other group members social cues to have no assistance and carried on assisting. Jane needed 2x verbal prompting to initiate termination/restoration of activity.

A. Jane is having difficulty recognising social cues from others. Would benefit from greater group involvement with emphasis on time management skills. Jane shows a level of motivation that indicates good rehab potential with medication.

P. Ask Jane to attend future baking groups. Jane to work on time management and social skills by planning and organising a meal with others.

References:

• College of Occupational Therapists (2003) Professional Standards for Occupational Therapy Practice London: COT [Download here (need to be a COT member)]
• Weed L.L. (1971) Medical records, medical education and patient care. The press of Western reserve University, 5th ed.[amazon]
• Borcherding S, Kappel C. (2002) The OTA's Guide to writing SOAP notes, SLACK [amazon]