An occupational therapy SOAP note example, one shortcut away

This pack turns an occupational therapy SOAP note example into an occupational therapy SOAP note template you can reuse, with a skilled nursing daily note and a classroom consultation note, plus the short sentences OTs keep in a cheat sheet. Type a shortcut in your EMR, Google Docs or the school system and the note appears, with this client's details filled in from text boxes and drop-down menus.

What's inside

• /otsoap: the full SOAP note. Pick how the client arrived, tick the activities you did (each one inserts a full sentence), choose the assist level and cue types, and enter trials so the accuracy is worked out and checked against the goal criterion.
• /snfnote: a skilled nursing daily note. Enter minutes for 97530, 97535, 97110 and 97112, and total timed minutes and units follow the 8-minute rule. Pick the task, assist level, cues and a skilled need statement from the menus.
• /consult: a classroom collaboration note with the setting, the strategies you modeled for the teacher and the follow-up date.

Shorter snippets for commonly typed sentences

Think of these as an OT documentation cheat sheet you never have to open:

• A subjective opener (/otsubj), sensory regulation (/sensact), fine motor (/finemotor), multi-step task (/multi) and toileting practice (/adl).
• Skilled terminology for occupational therapy in one line (/otskilled), goals not targeted (/otgnt), tolerated treatment (/tol) and continue plan of care (/cpoc). Use them in any occupational therapy progress note template too.

Notes at point of service

Make the defaults your own: your activities, your assist scale, your wording. Check units against your payer's rules.

Use /otsoap in your next session. Then save one sentence you type often as your own snippet: /otsubj is a good first one, and it takes seconds instead of retyping the same opener.