Occupational Therapy Soap Note

SOAP Note

Prepared by: John L. Stoops, TerraFirma Industries

This is a SOAP (Subjective, Objective, Assessment, Plan) note for Charlotte Rodriguez who is a 25-year-old female undergoing Occupational Therapy. The note carefully examines, assesses, and suggests a comprehensive plan for her current health situation.

Subjective

  • Stating frequent fatigue and difficulty concentrating

  • An occasional headache, especially in the late afternoon

  • No history of chronic conditions

  • No new medications

Objective

  • Height: 5'6"

  • Weight: 128 lbs

  • BP: 120/80

  • Heart Rate: 68 bpm

Assessment

  • No significant medical history, physical exam normal

  • The symptoms suggest routine stress or possible minor sleep disorder

Plan

  • Suggest a balanced diet, regular physical exercise, maintaining a regular sleep schedule

  • Yoga and meditation can also help to manage stress and improve sleep

  • Revaluation after two weeks to assess response to lifestyle modifications

Date of Note: March 22, 2050

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