SOAP Notes: PLAN

Question 1

What is included in the PLAN part of SOAP?

Answer 1

Last section of SOAP; relates to O and A; addresses last sentence of Assessment (“Client would benefit from…”)
• Where you determine and set forth specific tx that will be used to achieve OT goals.
• Base it on OT’s intervention plan from initial eval. (LTG, STG, frequency/estimated duration of tx)
• Include any follow-up, recommendations, and maybe a goal
• Include FREQUENCY and DURATION (ie: BID for 10 tx sessions; Continue OT for 1 hr 5x/wk…)

Question 2

What is the purpose of the PLAN note?

Answer 2

• For both you and any other OTPs to know what’s going to happen next.
• To justify need for continued skilled services

Question 3

Examples of PLAN note:

Answer 3

• Continue OT for 1 hr 5x/wk until anticipated D/C in 1 wk. Client will work on safe transfers, toileting and improving activity tolerance. Client will also be instructed in HEP to improve R shoulder AROM and strength.
• Continue 1 hr sessions 1x/wk to improve frustration tolerance, sequencing, and fine motor coordination for increased ability to participate in daily environments of home and school. In next session, provide parents with handout on problem-solving strategies. (Consider: trampoline with rapid bean bag toss)