Free Occupational Therapy Soap Note Template
Occupational Therapy Soap Note
Prepared by: [Your Name]
I. Subjective (S)
A. Patient Report
The patient reports feeling less pain in their right shoulder after two weeks of therapy but still experiences stiffness during daily activities. They express frustration with the limited range of motion when reaching overhead and state that the stiffness affects their ability to dress themselves independently.
B. Patient Goals
The patient hopes to regain full mobility and return to performing all daily tasks independently without discomfort.
II. Objective (O)
A. Range of Motion (ROM)
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Right shoulder flexion: 120° (improved from 100° last session)
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Right shoulder abduction: 100° (improved from 90° last session)
B. Strength
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Right shoulder strength: 4/5 (improved from 3/5 last session)
C. Functional Observations
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The patient required minimal assistance with dressing but still struggled with reaching overhead.
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The patient was able to complete 50% of their activities of daily living (ADLs) independently.
III. Assessment (A)
A. Progress
The patient is showing improvement in range of motion and strength in their right shoulder. However, there is still significant stiffness, especially in functional tasks such as reaching overhead and dressing. The patient’s motivation remains high, but their current level of disability limits their independence in ADLs.
B. Impression
The patient is responding well to the current therapeutic interventions, but they will need continued therapy to achieve full range of motion and increase strength in functional movements.
IV. Plan (P)
A. Short-Term Goals
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Increase right shoulder flexion and abduction to 130° within two weeks.
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Achieve 75% independence in ADLs with minimal assistance in two weeks.
B. Interventions
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Continue with strengthening exercises focusing on shoulder rotators and upper back muscles.
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Incorporate functional activities, such as reaching tasks, into therapy.
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Increase stretching and mobility exercises to address stiffness.
C. Follow-up
Schedule for follow-up in one week to monitor progress and reassess ROM and strength.
