SOAP Notes
What is included in the Subjective section of a SOAP note?
Direct quote from client, relates to how they perceive performance
Name 3 different types of documentation in OT
Screening report
Initial Evaluation/Plan of Care
Daily note
Progress note/Re-assessment
Discharge Documentation
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
The section of a SOAP note that includes your clinical reasoning skills/interpretation
Assessment
True or False
Documentation reports, according to AOTA, should always include an occupational profile and analysis of occupational performance
True
Meeting developmental milestones and ability to participate in family routines in a natural setting are outcomes related to what pediatric setting?
Early intervention
"The patient chatted while stacking 8 blocks into a tower" is an example of what section of a SOAP note?
Objective
Name 2 potential areas of focus for an evaluation in a PICU setting
Medical information/PLOF
Positioning/arousal
ADLs
Play
Reflection on a client’s strengths, challenges, and priorities is a clinical reasoning skill that OTs should use prior to what?
Goal writing
"Claire did not enjoy participating in Candy Land" should belong in what section of SOAP note?
Assessment
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
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
The "Plan" section includes frequency, duration, and what?
Intensity
What is unique about early intervention documentation?
Geared toward caregiver education and modeling skills for carryover
Long term goals are sometimes referred to as _______ projections.
Discharge