Tired of SOAP Notes Taking Forever? S10.ai Can Help.

Four sessions down. One kid crushed their fine motor goals, another had a meltdown mid-dressing — and your next client is already in the waiting room. You’re scrambling to remember what even happened in session one.

SOAP notes should be a helpful tool, not a time drain. But for most occupational therapists, they can feel like one more thing keeping you late at work.

“SOAP notes can be tricky because we’re so detail-oriented,” says Jeremy, a pediatric OT. But with the right system, she went from spending forever on documentation to knocking it out in minutes.

At S10.ai, we’re here to help you do the same.

What Are SOAP Notes in OT?

SOAP stands for:

Subjective: What the client or caregiver says about their condition.
Objective: What you observe and measure during the session.
Assessment: Your clinical interpretation of how the client is doing.
Plan: Your next steps — goals, interventions, and recommendations.

SOAP notes are essential for:

Tracking client progress
Communicating with caregivers and team members
Supporting documentation for insurance and supervision
Ensuring quality, client-centered care

Why SOAP Notes Matter

Great SOAP notes keep you organized and help your whole care team stay aligned. When done right, they’re not just required paperwork — they’re a clinical tool that saves you time and supports better outcomes.

“As a pediatric OT seeing up to seven kids a day, SOAP notes help me remember exactly what happened in each session,” Galindez shares. “Without them, it’s easy to lose track.”

Example SOAP Notes in Action

Adult Rehab Example

S: Client agreed to participate in a kitchen assessment.

O: Used walker to reach kitchen. Prepared tea with minimal cues.

A: Demonstrated independence in mobility and task planning.

P: No further OT services needed. Recommend discharge.

School-Based Example

S: Student reported hand fatigue from earlier writing task.

O: Demonstrated 90% accuracy in letter formation; 80% correct pencil grip.

A: Making progress, but hand fatigue limits endurance.

P: Continue handwriting goals. Add strategies for fatigue management.

Documentation Doesn’t Have to Be a Burden

SOAP notes don’t have to take up your evening. Here are a few tips to speed up your process:

Take quick notes during or right after the session while it’s still fresh.
Advocate for protected time — especially if you're a student or new grad.
Use repeatable phrasing and templates to save time and maintain consistency.

Do’s & Don’ts of OT SOAP Notes

✅ DO:

Be concise, specific, and function-focused
Connect every note back to goals and outcomes
Write with your future self (or your supervisor) in mind

🚫 DON’T:

Over-describe without clinical relevance
Assume longer is better — clarity always wins
Forget to tie your session to the client’s progress

📥 Download your free Occupational Therapy SOAP Note Template →

Includes a two-patient-per-page layout to help you stay focused and efficient — no more starting from scratch!

Occupational therapy Free Template

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