SOAP Notes
Evaluations
Outcomes
100

What is included in the Subjective section of a SOAP note?

Direct quote from client, relates to how they perceive performance

100

Name 3 different types of documentation in OT

Screening report
Initial Evaluation/Plan of Care
Daily note
Progress note/Re-assessment
Discharge Documentation

100

Name 1 outcome from OT services in a school-based setting

Improved handwriting/fine motor skills
Ability to follow directions/engage in classroom routines
Ability to socialize with peers

200

The section of a SOAP note that includes your clinical reasoning skills/interpretation

Assessment

200

True or False

Documentation reports, according to AOTA, should always include an occupational profile and analysis of occupational performance

True

200

Meeting developmental milestones and ability to participate in family routines in a natural setting are outcomes related to what pediatric setting?

Early intervention

300

"The patient chatted while stacking 8 blocks into a tower" is an example of what section of a SOAP note?

Objective

300

Name 2 potential areas of focus for an evaluation in a PICU setting

Medical information/PLOF
Positioning/arousal
ADLs
Play

300

Reflection on a client’s strengths, challenges, and priorities is a clinical reasoning skill that OTs should use prior to what?

Goal writing

400

"Claire did not enjoy participating in Candy Land" should belong in what section of SOAP note?

Assessment

400

Name a component of effective documentation (i.e. explaining jargon)

Avoid the appearance of multi-tasking
Separate facts from judgement
Review samples of site specific documentation
Be precise, concise, and clear in your writing

400

True or false: It is okay to work on skills outside of OT's scope of practice as long as the family and care team believe the goals are achievable.

False

500

The "Plan" section includes frequency, duration, and what?

Intensity

500

What is unique about early intervention documentation?

Geared toward caregiver education and modeling skills for carryover

500

Long term goals are sometimes referred to as _______ projections.

Discharge

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