Occupational Therapy SOAP Note Template

Occupational therapy notes succeed when they tie measurable performance to functional occupation: dressing, feeding, working, living independently. Reviewers want to see graded activity, adaptive strategies and progress toward ADL goals — not generic exercise logs. This free OT SOAP note template is built around that logic.

Subjective: function first

Anchor the note in the occupations the patient cares about. The chief complaint should name the activity (“difficulty buttoning shirts”, “fatigue during morning routine”), not just the body part. Record what changed since the previous session in functional terms, and capture one verbatim — a patient's own description of a morning routine often documents both motor and cognitive status at once.

Objective: measure performance

The template suggests the standard OT fields: grip strength in pounds, fine motor performance, ADL independence level, and sensory findings. Add standardized scores when you use them — COPM, FIM levels, nine-hole peg times — as custom rows with a value and a note. Then check the interventions actually delivered: ADL training, fine motor activities, sensory integration, adaptive equipment training. As with any billable note, dosage matters: what activity, what level of assistance, how many trials.

Assessment: justify skilled OT

State the trajectory toward each established goal (improving / plateau / regressing / goal met) and explain why skilled occupational therapy — task analysis, grading, adaptation — remains necessary rather than a home program alone. If progress has plateaued, say what you will change; a plateau with a plan is defensible, a plateau with copy-pasted notes is not.

Plan: grade up, equip, discharge

Note frequency, the home or caregiver practice assigned, equipment trials or recommendations, and the next session's focus. OT plans often include caregiver training — document who was instructed and in what.

Why a structured template helps OTs

• Field-specific prompts mean you record grip strength and ADL level every visit, making progress visible across notes instead of buried in prose.
• Checked interventions remove the repetitive typing of “ADL training, fine motor activities” from every note.
• Phrasing starters (“Patient demonstrates improved motor planning with…”) keep the clinical register without the blank-page cost.
• Consistency checks flag a missing patient identifier, undocumented section or implausible session duration before the note leaves your hands.

Workflow

Select Occupational Therapy in the generator; the Objective fields, intervention list and phrasing switch to OT. Fill the header (name, credentials such as OTR/L, practice, optional NPI), the patient identifier — initials recommended — and the four sections. Export as PDF via the print dialog, or copy the text into SimplePractice, your hospital EHR, or a school documentation system. The note is signed “Electronically signed by [name, credentials]”.

Everything happens in your browser: nothing is sent or stored, and closing the tab erases the note — export first. See a filled example on the SOAP note example page or the step-by-step guide.

Frequently asked questions