Question

An OTR® completes an intervention session with a client and documents it using the SOAP note format. In which section would the OTR® write "Client is making excellent progress toward goals and has met short-term goal 1"?

A. O
B. S
C. P
D. A

Answer 1

In the SOAP note format, an OTR® would document client progress and goal achievement in the Assessment section.

Step-by-step explanation:

The statement "Client is making excellent progress toward goals and has met short-term goal 1" would be documented in the Progress section of the SOAP note format by an OTR® (Occupational Therapist, Registered). The SOAP note format is a widely used clinical documentation tool that stands for Subjective, Objective, Assessment, and Plan. In the Assessment section, the therapist summarizes their clinical findings, which may include progress toward goals, as well as any changes in the client's status or achievements such as meeting short-term goals.

In the SOAP note format utilized by Occupational Therapists, the statement "Client is making excellent progress toward goals and has met short-term goal 1" would find its place in the Assessment section. This section serves as a concise summary of the therapist's clinical evaluation and observations. It encapsulates the client's progress, changes in their status, and noteworthy achievements.

In this specific instance, the therapist acknowledges the client's commendable advancement, explicitly stating their excellent progress towards established goals and the successful attainment of short-term goal 1. The Assessment section acts as a critical component in tracking the client's journey, providing a snapshot of their current status and the effectiveness of the therapeutic interventions. This structured approach ensures comprehensive documentation, facilitating communication among healthcare professionals, and aiding in the ongoing planning and adjustment of the client's occupational therapy plan.