How to write a Hand Therapy SOAP Note with examples

Writing an SOAP note for hand therapy may be completely different than writing a note for a more familiar setting like rehab or pediatrics, but the principles are the same.

In general, hand therapy notes should include specific information about measurements (ROM, strength, etc), splinting, scar tissue, wounds, patient education, response to treatment, and much more.

Let’s get into it.

Terms to know

Before writing hand therapy notes, you should be familiar with common terms associated with anatomy, physiology, and wound care. Here are a few to include in your notes.

How to write an Evaluation

An evaluation note should always include the basic elements of a SOAP note.  To read my guide on SOAP notes click here. 

Subjective

The subjective should contain these elements.

• Occupational Profile
• Hand dominance
• Diagnosis
• Medical history

Example

The patient is a right handed 68 year old male with a distal radius fracture s/p ORIF on 10/19/21 after a fall from a ladder 10/17/21.  He states 6/10 pain in R wrist. He works as an office manager with job duties to include lifting less than 25 lbs and typing.  Currently the pt is not working.

Social: Lives in a single level home with spouse.  Ind with all ADLs and IADLs prior. 

Past medical history: HTN, L knee surgery

Objective

Your objective note should include your measurements and assessments.  You should also list any treatment and education provided during the evaluation.  This might include splinting, exercise, wound care and provided handouts.

For this example, I included range of motion measurements, the quick dash assessment, splinting, and a home exercise program. You might also include strength testing with a dynamometer or measure circumferential edema with measuring tape.

Example 

Range of Motion

Strength: Not indicated

Quick Dash score: 56%

Fabricated a custom wrist cockup per MD orders and educated pt to wear splint for 24 hours per day for 4 weeks.  Educated pt on wear and care. 

Pt educated on a home exercise program and provided a handout for 6 pack exercises within confines of splint. 

Assessment 

The assessment should include

1. Problems (List and describe)
2. Impact on function
3. Needs

Problems should also be descriptive.  If the patient has limited range of motion, describe the end feel.  If the patient has a wound, describe its appearance and how it’s healing. 

Example

1. The patient’s problems include… (increased pain with movement, hypersensitive to touch, limited range of motion due to…, decreased strength, non-healing wound, etc)
2. Limiting the patient’s ability to…(cut food, meal prep, drive, return to work, etc)
3. Requiring…(skilled OT/PT to increase ROM, strength, and sensation to increase Independence with ADLs and return to work.  

The assessment should be well written, so a doctor or therapist can read your note and understand the patient’s primary problems and why your skill as a hand therapist is needed.

Plan

The plan should include 

1. The frequency and duration
2. Goals
3. Plan of care or planned treatments

Example

• Pt will attend therapy 3x per week for 4 weeks per doctor orders.
• Short term Goals
  1. Pt will increase wrist ROM by 10 degrees within one week
  2. Pt will make a functional fist within 2 weeks
  3. Pt will eat with R hand within 3 weeks
• Long Term Goals
  1. Pt’s pain will decrease to 1/10 within 4 weeks
  2. Pt will return to work within 10 weeks
• Plan of Care 

Treatments to include therapeutic exercises, therapeutic activities, e-stim, ultrasound, cryotherapy, hot packs, manual therapy, edema management, splinting, soft tissue immobilization, desensitization techniques, etc.

Documentation Manual for Occupational Therapy: Writing SOAP Notes

How to write a daily Progress Note

The most important part of the progress note is to document functional gains, your treatment, how the patient is progressing with therapy, and your plan for the future.

Usually, I mention the patient’s functional gains in the Subjective statement. In the objective section, I’ll list the treatment performed and attach a file with the plan of care listing all the activities performed.

In the assessment, I’ll discuss the patient’s progress, how they responded to therapy, and how the wound is progressing.

The plan should discuss any goals met and new treatments planned. You might also refer to the plan of care for specific activities performed.

Note: Some facilities will want you to include the specific treatment activities for each progress note in the objective section.

Example

Subjective

Pt states 5/10 pain in R wrist and compliant with home exercises program. Reports no issues with splint. Reports he still can’t use utensils with his R hand.

Objective

Pt placed in moist hot pack x10 min and completed therex x30 min and manual therapy for digit PROM and AAROM x10 min. Placed in R hand in ice pack x15 min post tx. Dressing changed. See plan of care for specific exercises.

Assessment

Pt progressing well in regards to ROM and pain. Pt appears to be less guarded today, but cont to have significant pain with digit ROM and may not be putting forth maximal effort during HEP. Pt’s skin under splint appears intact with no redness. Sutures intact with no signs of infection.

Plan

Pt will cont with plan of care and sutures to be removed next visit.

How to write a splint note

Sometimes a doctor will order a splint only evaluation. In this case, you should write the note like an evaluation, but do not indicate further treatment.

Your splint note should include the type of splint, custom/prefabricated, patient education, splint frequency, and any additional materials used.

Here’s a quick example.

Subjective

Patient is a 25 year old male with work related injury from a saw. Pt suffered a nail bed injury to the R IF and is referred to us for a tip protector splint. Pt Independent prior and works as a construction worker. Pt currently is not working.

Objective

The patient’s range of motion is WFL after reviewing HEP and 6 pack exercises. Fabricated a custom tip protector to reduce sensitivity and educated pt on wear and care. Issued pt extra roll of coban. Pt understands to return if the splint if it causes any irritation or redness.

Assessment

Pt has good ROM and is not a candidate for therapy. No further therapy indicated at this time as pt is referred for a splint only.

Plan

Pt referred for a one time visit for splint and will follow up with MD as needed.

How to write a Reevaluation

In hand therapy, a reevaluation should be completed based on your state and facility guidelines. Normally you should be updating measurements on a weekly basis and this can be included in a weekly progress note.

Sometimes you will need to do a reevaluation every 30 days or if if the patient has a change in status (surgery).

Your reevaluation should include the occupational profile, diagnosis, past medical history, and changes in measurements (ROM, strength, etc). You should also include updated goals to reflect the measurements and functional goals.

Lastly, you should make updates to the plan of care. Include what activities or exercises are now appropriate for the patient.

You may also need to make changes to the frequency and duration. For example, if your patient recently had surgery and is now only being seen for wound care, you may need to change the frequency and duration of treatment.

The discharge summary note

If your patient has been discharged from therapy, it’s best to write a discharge summary.　

Subjective

Pt is a 45 year old male s/p R MF trigger finger release. He was intially seen for therapy on 6/10/21 and is now discharged for therapy.

Objective

Strength

R hand: 85 lbs, L Hand: 95 lbs

Range of motion R MF: WFL

quickdash score:100%

Assessment

Pt has met all goals and shows no further need for skilled therapy. 

Plan

Discontinue therapy as no further treatment indicated. Pt to follow up with MD as needed.

Hand Therapy SOAP note Template

Conclusion

Hand therapy documentation is a skill of learning and practice. The more you learn, the more your documentation will improve.

If you’re becoming more proficient at documentation but have difficulty explaining technical terms, expand your knowledge by reading a hand therapy book.  

Here’s my new book on splinting without patterns.

And here’s another one I recommend.

Rehabilitation of the Hand and Upper Extremity, 2-Volume Set: Expert Consult: Online and Print, 6e

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David

David is the lead editor of OT Focus. He has been practicing as an Occupational Therapist since 2013. He specializes in acute care, hand therapy, and ergonomics.