Occupational Therapy SOAP Notes: Template and Worked Example
Occupational therapy SOAP notes organise a session into Subjective, Objective, Assessment and Plan. The useful distinction is between what someone told you, what you observed, how you interpreted it and what was agreed next. Four headings alone do not make a complete note.
This guide gives Australian OTs a copyable structure and a fictional example. Adapt it to your service, scope and records policy. It is not an NDIS funding report, an assessment instrument or a universal billing format. If you need the larger report, see our NDIS progress report guide.
Contents
What belongs in each SOAP section?
Queensland Health’s OT learner guide describes SOAP as a way of structuring notes. The prompts below are a writing aid, not a required national form. Use the documentation format your organisation requires.
| Section | Question to answer | Keep out of this section |
|---|---|---|
| S: Subjective | What did the participant or another identified person report? | Presenting a family account as something you witnessed. |
| O: Objective | What task, context, response and assistance did you actually observe? | Unrecorded scores, assumed ability or judgement about motivation. |
| A: Assessment | What is your interpretation of the recorded information and its limits? | New facts that appear nowhere in the source record. |
| P: Plan | What actions were agreed, with whom and for when? | A generic next-session statement with no identifiable action. |
Copyable OT SOAP note template
Start with the encounter details before the four sections. The following prompts belong in your approved clinical record, not in an unapproved public tool. Delete prompts after completing them; do not invent an answer to make a field look finished.
- Encounter: participant identifier, session date and time, location or delivery method, clinician and other people present. Record duration where required.
- S: identify the speaker, relevant goal or concern, and what changed since the previous contact.
- O: describe the occupation or task, conditions, assistance or cues provided, and the observed response. Record the source and date of any measure.
- A: explain what the information means for the participant’s goal, what remains uncertain, and whether comparison with earlier observations is valid.
- P: record the agreed next action, responsible person, follow-up timing and any communication required.
- Authorship: identify the author and completion time, with amendments made under your service’s records policy.
Fictional example: organising a morning routine
This example is invented to demonstrate wording. It contains no real participant information, standardised test results or recommended therapy dose. The proposed action is specific to the fictional conversation, not advice for another person.
S: Participant A said, “I want to get my bag ready before the support worker arrives.” Their sister reported that she usually gives reminders. These are accounts from the participant and sister, not observations of mornings outside the session.
O: In the session, Participant A placed their notebook and water bottle in the bag after referring to a written list. The therapist gave one verbal reminder to check the remaining item. The task took place at the dining table with the list visible. Performance without the list was not observed.
A: During this task, Participant A used the written list and still required a verbal reminder. This single observation does not establish independent performance in the usual morning routine. The sister’s report provides additional context but was not directly verified during this session.
P: Participant A agreed to discuss how the list worked at the next scheduled appointment. With the participant’s permission, the therapist will ask the sister for a dated account of the routine. No change to the agreed appointment schedule was made during this encounter.
Replace vague sentences with traceable observations
“Tolerated the session well” leaves the next reader guessing. Name the task and response instead. “Improved independence” also needs a comparison: the same task, setting and support conditions, or a clear explanation of what changed. If you do not have a comparable baseline, say so.
For example, “completed the checklist” is less useful than “located two listed items without prompting; therapist then prompted a check for the remaining item.” The second sentence tells the reader what happened without assigning an unsupported assessment score.
Ahpra’s shared Code of conduct sets expectations for clear, accurate records for the professions it covers, including occupational therapy. SOAP is an organisational aid; it does not replace those obligations.
When SOAP notes become evidence for a larger report
Keep a dated source trail. When preparing an FCA or progress report, select relevant encounters and explain the period they cover. Do not stitch every session note together and call the result a functional assessment.
Separate repeated observations from one-off events. A useful working table has the date, task, context, assistance, observed result and source. Different settings can explain apparently conflicting records. Preserve that difference instead of replacing it with a single confident sentence.
For a transfer between clinicians, use a shorter allied health handover that makes the outstanding actions visible. The recipient should not have to search months of SOAP notes to find the next agreed step.
A short check before signing
Read the note once for accuracy and once as the next clinician. Could they distinguish reported information from observation? Could they identify the action they are expected to take?
- Correct participant, encounter date, author and sources.
- No copied-forward findings presented as a new observation.
- No invented test scores, times, assistance levels or quotations.
- Interpretation stays within the documented evidence and the author’s scope.
- Agreed actions and unresolved questions are visible.
- Confidential information is stored and shared through approved channels.
Can AI help with the wording?
An AI-assisted draft needs checking against the original notes. Rewording must not turn a reported account into a witnessed event, turn an unmeasured item into a score, or add a recommendation the clinician did not make. Read our AI and professional obligations guide before choosing a workflow. This article does not introduce a new SOAP-note feature in Carearoo.
Frequently asked questions
Is a SOAP note the same as an FCA?
No. A SOAP note documents an encounter. An FCA draws on an assessment process and relevant evidence to address functional capacity. A series of session notes is not automatically a complete FCA.
Where should a family member’s account go?
Identify the person and record it as reported information. Do not present it as an observation made by the clinician. Explain its relevance without silently changing the source.
Can I copy this example into a client record?
No. It is fictional and only demonstrates structure. Record the actual encounter, information, reasoning and agreed plan for your participant.
Is SOAP mandatory for every Australian OT service?
This guide does not establish a universal mandatory format. Use your organisation’s documentation requirements and the professional obligations applicable to your work.
How this guide was written
Carearoo editorial guide, prepared with AI assistance and linked primary sources. Not independently clinically reviewed. Examples are fictional writing exercises, not treatment recommendations or records to copy into a client file.
Need to turn session evidence into a report?
Start with the report structure and a sample. Your assessment and review remain essential.