SOAP Notes
In an initial evaluation note, the "S" may contain all or part of the clients
Occupational profile
True or False - It is never permissible to report comments from caregivers and other professionals in the "S"
False - It is permissible (Appropriate to get info from others)
What are the two ways to organize information in the "O"?
Chronologically or categorical
This aspect of occupational therapy measures a client's ability to perform everyday tasks.
What is occupational performance?
What does the OTPF-4 tell us about assessment?
Provides important guidelines regarding assessment within the context of occupational therapy
The "O" should begin with a statement about the _____, _____, and ______ of the occupational therapy session. It may also include information about the duration of the session
Length, Setting, Purpose
True or false - It is important to emphasize the treatment media used in the session.
False - Focus is on skilled OT
The "A" should end with a statement that does what?
Justify need for continued therapy
This is established when OTs measure aspects such as strength, range of motion, and endurance but not the full spectrum of functional ability
What are performance components?
What does the OT code of ethics tell us about assessment?
The code of ethics provides ethical guidelines that apply to all aspects of occupational therapy practice, including assessment. It outlines principles that ensure assessments are performed in a responsible, professional, and client-centered manner.
What three primary things should be discussed in the "A"?
Problems, Progress and Potential
True or false - There should be no new data in the "A" that was not already discussed in the "S" and "O"
True
Complete the following formula for making an assessment statement:
_____, impact, ability to engage in occupation
Contributing factor
What are the two primary components of a problem statement?
Contributing factor and occupation
What does the scope of practice tell us about assessment?
Scope of Practice outlines the boundaries and responsibilities of occupational therapy practitioners, including the role of assessment in the therapeutic process.
The "P" should include what three elements?
Frequency, duration, purpose
True or False - The "S" section of the SOAP note can include information reported by the clients family or caregivers
True
What section would this statement fit under"
"Client would benefit from..." and "Client requires skilled OT services in order to..."
Assessment section
Why do we document?
Client care management, reimbursement, utilization review & management, legal implications, quality improvement, accreditation, education & research, business goals, client access, advocacy
What does the standard of practice tell us about assessment?
Regarding assessment, the Standards of Practice outline essential responsibilities in the evaluation process, focusing on accuracy, client-centeredness, professional competence, and adherence to evidence-based practice.
Initial evaluation, daily notes, progress notes, re-evaluation, and discharge notes
The "O" section show always be written in full sentences
False - The "O" section can include bullet points or lists, as long as the information is clear and concise
What section would this statement fit under:
"I don't go to my AA group as much as I used to because of my anxiety"
Subjective
This part of the evaluation process involves selecting appropriate assessments to measure performance based on the occupational profile.
What is analyzing occupational performance?
When we see measurement/assessment/evaluation/goal setting discussed in our formal official documents, this means we need to bring the ________ _______ to assessment and measurement as we bring it all other client interactions
Professional values