The most common documentation style seen is the SOAP note. SOAP is an acronym for Subjective, Objective, Assessment, and Plan. In the subjective piece of documentation the therapist will put what was said by the client or their caretaker. In the objective piece the therapist will write what they observe the client do. In the assessment portion the therapist will take what they collected in the subjective and objective parts and interpret it. In the plan portion, the therapist makes a plan or writes goals for the future treatment of the client.
In early intervention and schools, a therapist might often document using an Individualized Family Service Plan (IFSP) or an Individual Education Plan (IEP). The IFSP is begun when the child is 3 years of age and it also includes the parents in the plan. An IEP is used in special education programs in schools and can lead into getting a special education diploma.
A couple of others worth mentioning are narrative notes and progress notes. A narrative note is written in story type form and tells about treatment given, what the therapist observes, and what the client achieves in the session. A narrative note can be in SOAP note form but it does not have to be. A progress note tells what has been accomplished over a set amount of time. It is more popular than the narrative note.
These are just a few examples of documentation seen in occupational therapy. It is good to know that there are many variations of documentation as you never know what your professional setting will require.
In early intervention and schools, a therapist might often document using an Individualized Family Service Plan (IFSP) or an Individual Education Plan (IEP). The IFSP is begun when the child is 3 years of age and it also includes the parents in the plan. An IEP is used in special education programs in schools and can lead into getting a special education diploma.
A couple of others worth mentioning are narrative notes and progress notes. A narrative note is written in story type form and tells about treatment given, what the therapist observes, and what the client achieves in the session. A narrative note can be in SOAP note form but it does not have to be. A progress note tells what has been accomplished over a set amount of time. It is more popular than the narrative note.
These are just a few examples of documentation seen in occupational therapy. It is good to know that there are many variations of documentation as you never know what your professional setting will require.
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