Documentation for therapy services can be a time-consuming yet essential component of service delivery. Many practitioners and clinicians attempt to streamline their daily note process. Some critical details should not be overlooked, though it is still possible to create a concise note while including everything that reimbursement experts need to see.

Many professions, including occupational therapists, physical therapists, speech-language pathologists, ABA therapists, and others, use SOAP notes for their daily sessions. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. SOAP notes are valuable because they provide information about different therapy components, and since therapists use them widely, the interdisciplinary team can use them as a means of timely communication.

S: Subjective: What is the client saying about their experience?

Subjective information may include reports of pain, challenges since the last session, or what the client shares they can or cannot do. You may record behavior during the session for pediatric clients, including arousal level and engagement in therapy. You can also include reports from the client’s family or teachers.

O: Objective: What are you observing? What data can you collect?

Include any compensatory strategies your client uses, physical or cognitive strategies for participation, and data you collect. The objective section could include the percentage of trials completed correctly and the client’s level of support needed to perform the activity. If your client needed any adaptive equipment, assistive technology, or modification of a task, include that information here as well. It is vital to make sure that you focus on the active experience of the client rather than the therapist. For example, note that the “Client needed moderate physical assistance for bathroom mobility” rather than “Provided moderate physical assistance to the client.”

A: Assessment: What is your interpretation?

Consider what you wrote in the subjective and objective categories. What does this mean? You’ll use your clinical expertise to interpret the information into an analysis of the client’s performance. Note any improvement, regression, or progress toward your client’s goals. Refer back to the subjective and objective categories to support your assessment.

P: Plan: What is going to happen next?

Include the frequency, duration, and location of recommended services. If you are recommending discharge, include specific information about recommendations for follow-up. Otherwise, include detailed information about your intervention plan and how you will use it to address the problems noted in this session.

CBS Therapy is the premier provider of school-based and pediatric special education staffing services in the Northeast.

Learn more: https://cbstherapy.com/soap-notes-for-therapists/

Transitions are a part of everyday life at home and school. However, they can be challenging for children and adults alike, and the demands can be complex! During transitions, the sensory environment is more stimulating, and expectations are often higher than during lessons or structured activities. Often there is more noise in the room, lots of movement, and visual distractions. We expect students to follow multiple-step directions and navigate their bodies through the room while their peers do the same. The following strategies offer ideas to support our students during this frequent occurrence in the school day.

1. Calendar
Younger classrooms often have a visual schedule, but older kiddos can benefit too! Offer a written plan for students who can read. When a child asks what is next, refer them to the schedule to teach them to use it. As adults, we often use our planners or apps to keep track of our days. Learning to check a calendar is a tool that kids can use in their childhood and beyond. Be sure to keep your schedule updated to prevent unexpected changes.

2. Provide a Warning
Unexpected transitions are more challenging. Think of the last time you experienced a surprise fire drill. It feels alarming and dysregulating! Many children feel this way during routine changes. A simple way to prevent this is by giving the group advance notice of the upcoming transition. You can direct this by announcing how much time they have left or making it more concrete. For example, let them know they can color one more shape, and then they will wash their hands.

3. Keep It Structured
We have children with a variety of needs in our classrooms. It can be challenging to develop a transition routine when you have students who need different supports. Some children will complete the transition quickly and become impatient or unsure of what to do while waiting for the next direction. Offer an activity to keep the structure going. For example, when children complete an art project, they can grab a book and return to their seats. When they finish lunch, they can pick a center.

4. Sing it! Move it!
An efficient strategy for younger ones, singing provides a constant familiar activity while students complete their transition. You can use the same songs for daily changes to give an extra level of consistency. Similarly, offering a movement activity can provide a motor break and support the flow of the transition. Try marching to the bathroom, tip-toeing to cubbies, or walking heel-to-toe to another room.

5. Recognize a Job Well Done!
Transitions are a complex routine to learn for young children. Provide plenty of praise for students who follow directions and stay regulated. Providing positive reinforcement helps students understand what expected behavior looks like by observing what their peers are doing well.

CBS Therapy is passionate about helping children with special needs and serving the schools, therapists, and families who support them. New England’s premier provider of school-based and special education staffing services in the Northeast, CBS Therapy also has therapy clinics that offer speech-language, occupational and physical therapy services.

Learn more: https://cbstherapy.com/