Which aspect does the “O” section of a SOAP note cover?

The “O” section of a SOAP note specifically refers to objective, measurable observations made by the occupational therapist. This part of the note captures quantifiable data and facts about the patient’s condition, such as results from assessments, measurable outcomes, and observations during therapy sessions. These observations should be free from interpretation or opinion, focusing solely on what can be seen or measured, such as range of motion, strength, and patient performance in tasks.

The focus on objective measurements is critical as it provides a concrete basis for evaluating the effectiveness of interventions over time and contributes to tracking the patient's progress. This factual data is essential for planning future treatments and ensuring that goals are being met in an evidence-based manner.