SOAP

underlying factors
1. performance skills
2. performance patterns
3. context
4.activity demands
5. client factor


1. Client needs (Assist level) in (performing what occupational task) due to (underlying factor)
2. Client unable to (engage in what occupational tasks) due to (underlying factor)
e.g. consumer is unable to sustain employment more that 2 weeks due to absence of stress management skills


3. (Underlying factor) results in (what occupational deficit)
e.g. Aggressive behavior results in limited opportunities for social participation and repeated involvement with the juvenile justice system


## veteran needs or requires max assist ... ... is better than "Veteran is max assist..."

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Goal writing: FEAST Method
Function
e.g. in order to begin writing his name at school, the student will demonstrate ability to hold a crayon using tripod pinch by 10/19/08
e.g. the student will be able to hold a crayon using tripod pinch in order to learn to write his name at school by 10/19/05.
Expectation
e,g The client will...
Action
e.g.The client will perform a three-step cooking process
Specific Condition
e.g. The client will perform a three-step cooking process at wheelchair level after skilled instruction
Timeline
e.g. The client will perform a three-step cooking process at wheelchair level after skilled instruction by 3/16/05

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S = subjective

O=objective (measurable, quantifiable, and observable data obtained during the treatment session)
Client seen for ____minutes (In what setting) for (Purpose of the treatment session) for (For what expected functional gain)
e.g. Client seen in day room on unit for instruction in anger management techniques needed to maintain relationships and sustain employment

<--opening sentences, then, with a summary of what you observed. Being more professional in documentation Focus on client's response to the treatment provided, rather than on what the therapist did e.g. Client was asked orientation questions pertaining to the time of day. ==> When verbally cued to look at watch, client was unable to correctly identify time.

be specific about assist levels in what action

write from the client's point of view, leaving yourself out
e.g. client and family instructed in energy conservation techniques and demonstrated understanding by performing correctly

Client worked on placing pegs into a pegboard
=> Client worked on tripod pinch using pegs and a pegboard
==> client worked on tripod pinch in order to be able to grasp objects needed for ADL tasks
===> Client worked on tripod pinch using pegs and a pegboard in order to be able to grasp objects needed for ADL tasks.

make certain that it is clear that you were not just a passive observer in the session
Client compensated for shoulder flexion by leaning forward with whole body during prehension activities
==>Client required skilled instruction to avoid compensation at the shoulder during prehension activities

Avoid judging the client
E.G. Client was compliant or client was cooperative
==> client demonstrated ability to follow 3-step directions and sequence WFL.

A= Assessment , contains therapist's appraisal of the client's progress, functional limitations, and expected benefit from rehabilitation.describing what it means in your professional judgement, and its potential impact on the client's ability to engage in meaningful occupaion.

3P=> problems, progress, and rehab potential
1. inconsistencies between client report and objective findings
2. Factors not WFL that can be influenced by OT intervention
3. progress or indications tht the treatment being provided is effective
otnetial for success in rehabilitation
### A is not a place for you to put new data, please support new founding in S or O also!

End with statement "Client would benefit from ... ..." for justifying continued treatment

Underlying factor -> impact -> ability to engage in occupation
E.g. Deficits in UE strength and activity tolerance limit client's ability to complete basic self-care tasks


P = Plan, specific interventions to achieve the goals.
Client will (action verb) (Skill) (under what conditions) (for what function or occupational gain - if not already indicated ) (by when)
e,g, consumer will continue sheltered workshop program 5 days/wk in order to increase work skills. Consumer will attend to task for 60 minutes with no verbal cues within 1 week in order to increase independence as a worker

for psychiatric record:
Problem statement: problem, and Behavirla manifestations

Problem: Noncompliant behavior
Behavioral Manifestations: client disobeys foster parents by running away, refusal t o follow rules or requests and engaging in sexual activitiy, resulting in six foster home placements in the past 4 years

Problem: suicide risk
Behavioral Manifestations:
During the week prior to admission, the client verbalized suicidal ideation, stating that life was no longer worth living. On the day of admission he purchased a handgun