Foundations blog 2

Last week and this week we have been discussing SOAP notes and how to write them. I have been exposed to SOAP notes before. I use to be a receptionist at a veterinary hospital. Sometimes we would have to read through veterinarians physical exam (SOAP notes) notes to answer a question that an owner had. There were five doctors at the practice and only one followed the SOAP notes similar to what we do. I appreciated this vet! It made understanding what was going on with the patient easier and finding information that had been discussed with the owner easier, so that we were not always bugging the vet. I understand the importance of writing a good SOAP note. The SOAP note used at the vets office is similar to what OT's use. A SOAP not is defined as follows: S-subjective (what client says), O-objective (what OT sees or does), A-assessment (interpretation of S & O), and P-plan (goals). I was confused on how the 'A' applied in OT. When I look at the word assessment, I think of a test to be performed on a client. It wasn't until further explanation that the 'A' is the summary of the 'S' and 'O' that the process made sense. I am excited to try my hand at writing a SOAP note. I want to be proficient at writing SOAP notes. I know how much I relied on an individual being proficient with their notes. I realized that insurance companies or other therapists will rely on my notes on day in the same way.