S.O.A.P. Note Guide
S: Subjective
O: Objective
A: Assessment
P: Plan
To ensure you have each part in the note, start each section with the letter of the SOAP note that it pertains to.
Summary of what can be included in each section
S: Subjective
How the student is feeling (they tell you)
Who is present? (parent, teacher, etc)
O: Objective
The student’s behavior (alert, focused, happy, angry, etc)
Measurable data from your session (usually based on the goals you are working on)
This could include data from questionnaires, behavior scales, etc
You need to include numbers/percentagesThis is where you would document any education provided (exercise program, handouts, etc)
A: Assessment
This is where you describe what is going on based on the Subjective and Objective data.
You describe your impressions and interpretation of the information.
Draw on your expertise
Is the student progressing? Regressing? Close to meeting goals?
WAVA, ISWA, AZVA, ISAZ, and Oregon Virtual schools require a percentage for the Assessment or measurable data.
P: Plan
This is what is happening next. It can include what you will work on in the next session. It can include homework you have given the student.
The following are sample SOAP notes written that follow the expectations for the notes.
Occupational Therapy
S: Student arrived on time for session and cooperated well with all tasks. Student stated that he is experiencing hand fatigue during lengthy writing assignments, and his mother shared that this leads to increased frustration during classes.
O: Student engaged in a writing task that involved copying two sentences from a model on computer screen. He utilized a mature grasp on his pencil for 5 minutes and produced a writing sample that was 75% legible, 60% accurate for spacing between words, and 65% accurate for baseline orientation. He needed minimal verbal reminders to increase spacing between words.
A: Student is making gains towards his writing goals (last session his handwriting was only 65% legible). He benefits from increased visual supports during writing tasks and copying from a model. He is limited by poor recall of letter formation and overall hand strength.
P: Continue working towards handwriting goals to increase class participation and ability to produce legible written work. Next session to focus on writing 2+ sentences using regular lined paper and activities to improve hand strength.
Physical Therapy
S: Student presents to session ready and without any concerns. States she practiced her exercises throughout last week.
O: Session focused on lower extremity strengthening exercises aimed at improving the student’s safety and independence with stair navigation, as there are 6 steps with rails to enter/exit the school (home) environment. Student ascended and descended the 6 steps using the rail on the right and carrying a small bag in the left hand for 5 trials. Verbal cueing provided for using a step-through gait pattern. Visual cues also provided through mom and the student drawing circles of different color on each step with sidewalk chalk, This was used to encourage proper foot placement on each step. As a motivating factor, student was asked to complete an outdoor scavenger hunt in the yard between each step and carry their requested item back up the steps with them in the bag. Student successfully completed 4/6 trials using the desired gait pattern.
A: Student tends to use momentum to power up the stairs and has difficulty with eccentric control during descent. Dynamic valgus at the knee noted during descent as well. He has made 65% progress toward goals.
P: Focus on lower extremity eccentric strengthening exercises and mid-range control in order to improve body mechanics postural stability during stair negotiation.
Speech Therapy
Language:
S: The student logged in on time and was attentive, cooperative, and put forth satisfactory effort throughout.
O: During structured language activities, the student demonstrated the ability to name
antonyms with 75% accuracy
A: The student has improved with his ability to name antonyms since his previous session. The goal is 80% achieved.
P: Continue addressing current IEP goals.
Articulation:
S: The student logged in on time and was attentive, cooperative, and put forth satisfactory effort throughout.
O: During naming tasks, the student was observed to produce /g/ in the medial position of phrases with 60% accuracy.
A: The student did not improve with pronunciation of /g/ in the medial position since the previous session. The goal is 60% achieved.
P: Continue addressing current IEP goals.
OR
S: ST participated willingly and cooperatively in all activities. Per ST/CT/Teacher report, ST was
able to engage in xxx activity in order to engage in conversational intent with a peer.
O: We focused on pragmatic language goals/objectives: initiation/maintenance of conversations,
asking a question to follow up on a conversation, turn taking, figurative language, eye contact,
etc. ST participated in pragmatic language tasks: initiation/maintenance of conversations,
asking a question to follow up on a conversation, turn taking, figurative language, eye contact,
etc. with x% accuracy given minimal/moderate/maximal visual and/or verbal prompts.
A: ST improved/decreased/maintained accuracy when taking previous data into account. Include percent of the goal is achieved.
P: Continue addressing pragmatic language goals/objectives: initiation/maintenance of
conversations, asking a question to follow up on a conversation, turn taking, figurative language,
eye contact, etc.
Mental Health
S: The student logged in on time. The student states he feels sad and tired.
O: The student appears distracted and tired with frequent yawning and puffy eyes/bags. Practiced breathing techniques for use when anxious. Student was able to recall steps 2 of 4 trials. Reviewed journal and student completed 3 of 5 entries. The student walked outside today meeting his daily goal for outside activity.
A: The student appeared exhausted and depressed. He is having difficulty with remembering tools for breathing techniques and is also not completing his journaling which may help him recognize his feelings. He did show improvement with outside activity by going outside today. The student is 30% toward achieving a goal.
P: Plan to continue to work toward the goals of IEP. Students to try to journal 4 times before the next session and get outside 1 time per day for at least 5 minutes.
Specialty Teachers
S: The student logged in on time. The student said he has been wearing his hearing aids.
O: Per parent report, student needed verbal reminders 3 of 5 days this week to wear both hearing aids during school lessons. The student was able to list 2 of 3 ways to communicate his hearing loss to a peer. The student has learned 5/10 new ASL signs presented last week.
A: The student still requires outside assistance to remember hearing aids. He is getting better at communicating his hearing loss to peers to help build relationships. He is progressing with learning ASL signs. The goal is 50% achieved.
P: Will continue to work toward goals at our next meeting. I will plan to meet with the classroom teacher to discuss strategies to help the student next week. The student will practice his new signs this week and teach his mom the signs he has mastered.