Occupational therapy SOAP note template and examples
An occupational therapy SOAP note template with an OT data table, plus paediatric and adult examples for each section.
✓Objective table with cueing levels
✓Paediatric and adult sample entries
✓Lines for regulation and set-up
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What's inside
S — Subjective
O — Objective
A — Assessment
P — Plan
Therapist Sign-off
Preview · 5 sections
Occupational Therapy SOAP Note
Client
Session date
Therapist
Session length
Session type
Attendance
Caregiver present
Goals addressed
S — Subjective
Client, caregiver, or teacher reportWhat was reported since the last session: home, school, sleep, health, equipment, and the client's own aims for today.
O — Objective
Goal / Target
Activity and Set-up
Performance (trials, time, accuracy)
Assistance / Cueing Level
Notes
Fine motor / hand skills
Self-care task
Regulation / sensory participation
Regulation and engagement during the session
Environmental set-up and equipment used
A — Assessment
Clinical interpretation of today's sessionCompare with the goal and with previous sessions. Written by the treating therapist.
P — Plan
Plan for next session
Home practice given and who received the instructions
Communication with school or team
Therapist Sign-off
Therapist
Designation
Registration
Date
How to fill it in
1
S — Subjective
What the client, carer or teacher reported since the last session, kept to the goals.
More guidance
Record what the client, parent, carer or teacher reported since the last session: changes at home or school, sleep, illness, mood, new equipment and the client's own aim for today. Quote briefly when the words matter. Keep it relevant to the goals; long background belongs in the assessment.
2
O — Objective
Activity, set-up, measurable performance and assistance level for each goal worked on.
More guidance
For each goal worked on, record the activity, the set-up (seating, tools, positioning) and measurable performance: trials, time, accuracy, distance or steps completed. Add the level of assistance or cueing in your clinic's agreed terms. Write what happened rather than how you felt it went.
3
Regulation and engagement during the session
Arousal, attention, fatigue or pain across the session, and what changed them.
More guidance
Describe arousal, attention and engagement across the session and what changed them: a movement break, a quieter room, a preferred activity. For adults, note fatigue, pain behaviour or anxiety. This line explains variation in performance and is often the first thing a covering therapist reads.
4
Environmental set-up and equipment used
Room, seating and equipment used, so the next therapist can repeat the conditions.
More guidance
List the room, seating, equipment and adaptations used so the next therapist can repeat the conditions. Note anything new you tried and how the client responded to it.
5
A — Assessment
Your interpretation of today's performance against the goals and earlier sessions.
More guidance
Write your interpretation of today's performance against the goals and previous sessions. Note what helped or limited performance and whether the current approach should continue. This is your clinical reasoning as the treating therapist, so keep it specific to the data in the objective section and avoid carrying forward text from earlier notes.
6
P — Plan
Next session's plan, home practice given, who received it, and anything to arrange.
More guidance
State what you will do next session, any change of approach, the home practice given and who received the instructions. Add anything you need to arrange, such as a call with the teacher or an equipment order. For a covering therapist, a clear plan is the most useful part of the note.
7
Communication with school or team
Calls or meetings with school or team, what was agreed, and consent.
More guidance
Record calls, messages or meetings with teachers, doctors or other therapists and what was agreed. Keep it factual and note the family's consent to sharing. Summarise the decision rather than pasting a message thread into the note.
Occupational therapy SOAP note template and examples: filled sample
Fictional entries, initials only, showing the level of detail to aim for. Impression and summary sections are left for the treating clinician.
S — Subjective
Paediatric: Mother reports V. fastened his shirt alone on 3 mornings this week; slept poorly after a family wedding on Sunday. Adult: Mr S. reports he made tea twice this week using the kettle tipper; right shoulder 'stiff in the morning'.
O — Objective
Paediatric: Cutting a 15 cm curved line with child-sized scissors, seated with feet on a block: stayed within 5 mm of the line for about two-thirds of its length over 3 trials; 2 verbal cues to turn the paper. Adult: Upper-body dressing seated on the bed: put on a front-opening shirt in 4 minutes with minimal physical help to thread the left arm.
Regulation and engagement during the session
Arrived crying after a long auto ride; settled after 8 minutes on the platform swing and joined table work. Engagement dropped in the last 10 minutes, so the session ended with a preferred puzzle.
Environmental set-up and equipment used
Treatment room 2, blinds half closed. 30 cm chair with footblock, slant board, built-up pencil grip. First trial of a weighted pencil; V. asked to stop after 2 minutes.
P — Plan
Paediatric: Next session, repeat curved cutting on a thinner line and introduce two-handed lacing. Home: button practice daily, explained to grandmother in Tamil. Adult: Move to lower-body dressing seated; family to buy a long-handled sponge.
Communication with school or team
Phoned class teacher for 10 minutes; agreed V. may use the slant board for copying tasks from Monday.
OT SOAP note vs narrative session note
SOAP note
Narrative note
Structure
Four fixed headings plus a data table
Free text
Separating fact from opinion
Built in: objective data and assessment sit apart
Depends on the writer
Reading it later
Quick to scan for data on a goal
Slower; data is spread through the text
Best for
Regular sessions toward measurable goals
One-off consultations or complex team meetings
Feeds into
Progress reports and discharge summaries
Mainly the clinic record
Tips and mistakes to avoid
Do
Agree assistance and cueing terms across the clinic and use them in every note.
Write the note the same day, before set-up details fade.
Note who attended and the language used for home instructions.
School notes can be shorter, but keep the data line and the plan.
In healhab, session notes stay with the patient record for later progress reports.
Avoid
A subjective section that repeats the full history every session.
Objective entries like 'did cutting, good' with no goal or help level.
Copying the last assessment line forward without new evidence.
A plan that says only 'continue'.
About this session note
An occupational therapy SOAP note records one session in four parts: what the client or carer reported (Subjective), what you measured and observed (Objective), your interpretation (Assessment) and what happens next (Plan). This free template adds an OT data table for activity, set-up, performance and assistance level, plus lines for regulation and environment.
Every individual or group OT session
Teletherapy with a parent running the activity
Co-treatment, naming the other discipline present
Short school-based sessions needing a full record
Read more
SOAP is the most widely used format for OT daily notes. A good note lets another therapist run the next session: goal-linked data, the help given and a specific plan.
The objective table records activity and set-up as well as performance, because OT results depend on positioning and tools. Examples cover subjective, objective and plan; the assessment is yours.
Questions
How long should an OT SOAP note be?+
Long enough for another therapist to run the next session from it. For 45 minutes that is often a few lines each for S, A and P and a few rows of objective data.
What goes in the objective section of an OT SOAP note?+
Measurable performance on each goal: the activity, set-up and equipment, trials or time, accuracy and the level of assistance or cueing. Notes on regulation and engagement follow the data.
Can I use this for a pediatric OT SOAP note?+
Yes. It was written with paediatric sessions in mind, with a regulation line and room for carer reports. It also suits adult sessions.
Is there an OT SOAP note example?+
Yes. The section guides show fictional paediatric and adult sample entries, initials only, for S, O and P. The assessment section has no sample, because it is the treating therapist's own reasoning.
Is an OT daily note the same as a SOAP note?+
A daily note is any record of a single session, and SOAP is one format for it. Schools, hospitals and insurers recognise SOAP most widely.
Should the assessment section be in full sentences?+
Ideally, yes. Brief reasoning in full sentences is easier to read and defend months later. Limit abbreviations to those your clinic has agreed.
Can I write OT SOAP notes online free?+
Yes. Fill in the template in the free editor without signing up and download each note as a PDF. Drafts stay in your browser, so use a computer only you can access.
