What type of observations should be recorded in the "S" section of a SOAP note?

The "S" section of a SOAP note is dedicated to capturing the client's subjective complaints and views. This portion reflects the individual's personal experiences, thoughts, feelings, and perceptions about their condition and therapy. Including this subjective information is critical for understanding the client's perspective and how they perceive their symptoms, challenges, and progress. These insights can guide the occupational therapist in tailoring interventions that align with the client's needs and expectations.

In contrast, the other sections of the SOAP note serve different purposes. The "O" section focuses on measurable and objective observations made by the clinician, while the "A" section combines both subjective and objective information to assess the client's condition, and the "P" section outlines the plan for future treatment, including any long-term treatment goals. Each section has a specific role in creating a comprehensive documentation of the client's status and treatment plan, with the "S" section specifically aiming to emphasize the client's voice in the therapeutic process.