An occupational therapy SOAP note records one session in four parts. Subjective is what the client and their carers report, Objective is what you measured and observed, Assessment is your clinical reasoning about function, and Plan is what happens next. In Australian practice, the Assessment section is what NDIS reports and funding decisions are later built on.
Most SOAP note guidance written for occupational therapists comes out of the United States, where documentation is shaped by insurance billing and medical necessity language. Australian OTs write into a different system: notes have to satisfy the Occupational Therapy Board's competency standards, usually have to support NDIS plan reassessment reports, and have to hold up under Ahpra's health record obligations. This guide covers each section, a worked example, a reusable template, and the places where Australian requirements bite.
What is a SOAP note in occupational therapy?
SOAP stands for Subjective, Objective, Assessment and Plan. It is a session note format borrowed from medicine and adapted across allied health, and it suits occupational therapy because so much OT work produces measurable, observable data: transfers completed, prompts required, time on task, equipment trialled. BIRP and DAP are more common in talk-based disciplines, and our comparison of clinical note types sets the formats side by side, with the general principles in our complete guide to SOAP notes.
What goes in each section of an OT SOAP note?
Subjective
What the client, their family, support workers or teachers reported. This section carries more weight in occupational therapy than in most disciplines, because the people around the client hold the information about performance at home, at school or at work that you cannot observe in a clinic room. Record how tasks went since the last session, changes in routine, pain or fatigue reported, what they want to be able to do, and any equipment or strategy that was abandoned. Keep your interpretation out of it.
Objective
What you did and what you measured. This is the section that makes OT notes defensible, and it is where most notes are thin. It should include:
- The activity or assessment used, described specifically enough to repeat.
- Performance data: what was completed independently, what needed prompting, the level of assistance, how long it took, how many attempts.
- Standardised measures administered and their scores, for example a Canadian Occupational Performance Measure rating.
- Equipment or environmental modifications trialled, and the response to each.
"Client did well with the kitchen task" is not objective data. "Client completed a hot drink preparation task with one verbal prompt for kettle safety, in 4 minutes 20 seconds, using the trolley for transport" is.
Assessment
Your clinical reasoning about what the data means for function, not a repeat of the Objective section. This is the part a funder, a reviewer or another clinician reads first, and it should cover:
- How performance today compares to the baseline you recorded, and against which measure.
- Progress towards the client's goals, stated against something you can quantify.
- What is limiting performance: the impairment, the task demands, the environment, or a combination.
- Your judgement about what to change, and why.
Plan
What happens next, specific enough that a colleague could pick it up: next session's focus, home programme or task practice with dosage, equipment to be ordered or trialled, referrals, education provided to the client or carers, and anything to review at a set date.
What does an occupational therapy SOAP note look like?
The example below is fictional and written for illustration only.
Subjective: Participant reported she has been "getting stuck" preparing lunch and skipping the meal about three days a week. Support worker reported she declines assistance when offered. Participant stated her priority remains preparing her own meals without supervision.
Objective: Home kitchen, 50 minutes. Completed a sandwich preparation task with set-up assistance to retrieve items from the lower cupboard and one verbal prompt to sequence steps. Task completed in 11 minutes, against 17 minutes and three prompts at baseline four weeks ago. Standing tolerance at the bench 6 minutes before requesting to sit, up from 3 minutes. Perching stool trialled and accepted. COPM performance rating for meal preparation 5, up from 3.
Assessment: Improved sequencing and standing tolerance are translating into meal preparation independence, with the remaining barrier being low cupboard access rather than the task itself. Reduced prompting suggests learning is holding between sessions. The perching stool addresses fatigue but not reach, so reorganising storage is likely to produce more functional gain than further task practice.
Plan: Reorganise frequently used items to bench height with the participant next session, then re-measure the task. Continue standing tolerance practice twice daily as tolerated. Order perching stool and review fit on delivery. Provide written fatigue management strategies to the participant and support worker. Re-administer COPM in four weeks for the plan reassessment report.
How do OT session notes feed into NDIS reporting?
This is where Australian OT documentation diverges most sharply from the US guidance that dominates search results. If your client is an NDIS participant, your session notes are the raw material for a plan reassessment report, and the NDIS is explicit about what that report must contain.
Its guidance for allied health providers asks you to outline the type of service, therapeutic approach, duration and frequency of supports, and the goals worked towards. It then asks you to summarise the participant's functional capacity at the start of the plan period, describe the assessment measures used to quantify it, give evidence of the therapies trialled, and describe progress against goals using those same measures. Barriers to progress and any risks must be documented with how they were addressed, and recommendations must be evidence based and linked to the participant's goals.
Read that list back against the SOAP structure and the implication is obvious. If your Objective section carries a standardised measure at baseline and at intervals, and your Assessment states progress against goals rather than describing the session again, the report largely writes itself. If your notes say "good session, client engaged", you will be reconstructing six months of evidence from memory.
The same logic applies to a functional capacity assessment, which the NDIS describes as an official assessment of a person's ability to perform daily tasks at home, at work and in the community, across six categories: communication, learning, mobility, self-care, self-management and social interactions. Occupational therapists are among the professionals qualified to complete one, and session notes organised around those categories make the assessment far less painful to write.
For the reporting layer above session notes, see our guides to writing NDIS progress notes and writing NDIS goals.
What are the record-keeping rules for Australian OTs?
Three layers apply, and none of them are optional.
The competency standards. The Australian occupational therapy competency standards have been in effect since 1 January 2019, and the Occupational Therapy Board expects all occupational therapists to understand and apply them. They cover four areas: professionalism, knowledge and learning, occupational therapy process and practice, and communication. Documentation sits inside that last area.
Ahpra's health record obligations. Ahpra publishes a managing health records resource that the Occupational Therapy Board is one of eight National Boards to have developed or approved for use. It sets out five expectations: keep good health records, use processes that support them, treat continuity of care as part of keeping them, keep records private and confidential, and recognise patients' right to access the information in them. A self-reflective tool on the same page is worth running your own notes against.
Privacy and retention law. Health information is sensitive information under the Privacy Act, so the Australian Privacy Principles apply, in particular APP 11 on security and APP 12 on access. Retention minimums are set by state and territory law. In Victoria the Health Records Act 2001 requires providers to keep records for at least seven years from the date of last service, and for a client who was a child, until they turn 25. Check the rule where you practise.
A reusable OT SOAP note template
Copy this into your note template and fill it in during or immediately after the session:
- Session details: date, duration, setting, who was present, funding stream.
- Subjective: client report, carer or support worker report, changes since last session, stated priorities.
- Objective: activities and assessments used, performance data with numbers, assistance level and prompts, measure scores, equipment trialled and response.
- Assessment: comparison to baseline, progress against each goal, limiting factors, judgement about what to change.
- Plan: next session focus, home programme with dosage, equipment actions, referrals, education provided, review date.
- Author: name, role, registration, date and time written.
If you are building this into practice software rather than a document, our guide to designing a clinical note template covers the field-by-field decisions, and the same structure is worked through for speech therapy SOAP notes.
What mistakes make OT SOAP notes fail review?
- No baseline. Progress cannot be demonstrated against a measure you never recorded. Capture it at the start of the plan period, not when the report is due.
- Objective data with no numbers. Assistance levels, times, repetitions and prompt counts are what make a note evidentiary.
- Assessment that restates Objective. If the section contains no reasoning, it is not an assessment.
- Goals in the file, not in the note. Each note should connect to a stated goal, or the link to funding is invisible.
- Copy-forward. Duplicated notes across sessions are the clearest signal to a reviewer that the record is not real.
Does note-taking software actually help?
It helps with the structural parts, not the clinical ones: enforcing the same fields every session so baselines are never missed, carrying goals into the note, and keeping measure scores in one place so a trend is visible without rereading the file. What it cannot supply is reasoning. The Assessment section has to be yours.
PractaLuma is AI-native practice management software for Australian mental-health practices, and while occupational therapy sits outside that core focus, the documentation problems are the same shape: structured clinical notes, standardised assessments tracked over time, and report writing that draws on notes already written. See the full feature set or check pricing.
Frequently asked questions
How long should an occupational therapy SOAP note be?
Long enough that another clinician could continue treatment, short enough that you actually write it after every session. Usually a paragraph or two per section, with Objective and Assessment carrying most of the length.
Should OTs use SOAP or another note format?
SOAP suits occupational therapy because so much of the work generates observable, measurable data that fits the Objective section cleanly. DAP and BIRP were designed for sessions that are largely narrative. Whichever you choose, use it consistently across the practice, because the value comes from comparability across sessions and clinicians.
Do NDIS participants get to read my notes?
Clients have a right to access information in their health records under APP 12, and the NDIS also asks you to share plan reassessment reports with the participant. Write every note on the assumption that the person it is about will read it.