Title Page

  • Session Date

  • Patient Name

  • Occupational Therapist Name

  • Location

Occupational Therapy SOAP Note

Subjective Information

  • In this section, write down the patient's health concerns, past and present medical history, symptoms, and other vital information. Photos can also be attached as supporting evidence.

  • Primary Concern(s)

  • Patient History

  • Review of Symptoms

  • Other Notes

  • Supporting Photos/Documents (Optional)

Objective Information

  • In this section, note all quantifiable data about the patient's physical and functional state, including the following:

    • Vital signs
    • Findings from physical examinations
    • Laboratory results
    • Imaging results
    • Other diagnostic information

  • Physical and Functional Condition

  • Other Notes

  • Supporting Photos/Documents (Optional)


  • In this section, give your professional opinion about the patient's condition considering the subjective and objective data provided by the patient. This can include a summary of the patient's diagnosis, recovery progress, and areas for improvement.

  • Problem or Diagnosis

  • Differential Diagnosis

  • Other Notes


  • In this section, specify the goals for the patient and the steps required to achieve them. This can include exercises, rehabilitation programs, interventions, or referrals to other healthcare professionals.

  • Treatment Plan


  • Name and Signature of Occupational Therapist

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.