Every guide to occupational therapy SOAP notes teaches you the same four letters. Subjective, Objective, Assessment, Plan.

None of them mentions that two numbers inside the note change what the visit is worth. One is the number of things your Plan field is required to name, which is four. The other is the share of treatment minutes delivered by an assistant, where crossing ten percent costs fifteen percent of the payment.

Here are three blank templates, three worked examples across outpatient, pediatric and skilled nursing settings, and both numbers explained from the regulation that sets them.

Key Takeaway: An occupational therapy (OT) SOAP note records the patient's report, the therapist's measured findings, the clinical reasoning, and the plan. For Medicare Part B outpatient occupational therapy the plan is not a free-text line. 42 CFR 410.61 requires a written plan of treatment that "prescribes the type, amount, frequency, and duration" of the services and "indicates the diagnosis and anticipated goals" [1]. A second rule governs who delivered the care. Since 1 January 2020, claims for services furnished in whole or in part by an occupational therapy assistant (OTA) must include the prescribed modifier, and since 1 January 2022 those claims are paid at 85 percent of the amount otherwise applicable [2]. "In whole or in part" means the assistant furnished all the minutes, or a portion exceeding 10 percent of the total minutes for that service or unit [2]. Sully.ai drafts the note from the session and keeps treatment minutes attributed to the clinician who delivered them.

What an OT SOAP Note Has to Carry

SOAP is a general clinical format borrowed into occupational therapy. The borrowing works, but it is imperfect in two specific ways, and both are fixable inside the note.

The Four Fields, and What Each One Is For

You know what the letters stand for, so this is brief.

Subjective is the patient's report. In occupational therapy that includes what they tell you about performance at home, which is often the most useful sentence in the note.

Objective is what you measured and observed during the session.

Assessment is your clinical reasoning. Specifically, it is where you say why this session required the skills of a therapist rather than a home program or a supervised exercise.

Plan is the treatment plan. For Medicare Part B this is a regulated document with named contents rather than a closing sentence [1].

The two sections after this one are about the Objective and the Plan, because those are the two the borrowed format handles worst.

Why the Objective Field Pulls OT Off Its Own Ground

Here is the first thing no competing page says, and it is an argument about clinical reasoning rather than compliance.

The Objective field invites measurement. The easiest things to measure are impairments: range of motion in degrees, grip strength in kilograms, manual muscle testing grades. Those numbers are precise, they are repeatable, and they fill the field quickly.

They are also the numbers least able to distinguish occupational therapy from a supervised exercise program.

What makes the service occupational therapy is performance of occupation. A note full of goniometry documents a body part. It does not document what the patient could not do before the session and can do now.

The fix is a wording habit, not a longer note. For every impairment measure you record, record the occupational performance it limits, in the same line.

Grip strength of 18 kilograms is an impairment. Grip strength of 18 kilograms with the patient still unable to open a prescription bottle is occupational therapy. Same measurement, same session, and only one of them makes the case.

The Two Numbers That Change the Note

What 42 CFR 410.61 Requires the Plan to Name

Outpatient occupational therapy has to be furnished under a written plan of treatment [2]. The regulation is specific about what that plan contains:

"The plan prescribes the type, amount, frequency, and duration of the physical therapy, occupational therapy, or speech-language pathology services to be furnished to the individual, and indicates the diagnosis and anticipated goals." [1]

Read that as a list. Type. Amount. Frequency. Duration. Diagnosis. Anticipated goals. Six items, four of them describing the service itself.

Now read the Plan field in almost any published OT SOAP example:

P: Continue POC 2x/week.

That is frequency. It is not type, it is not amount, and it is not duration. One of six.

Type is which interventions you will actually deliver. Amount is how much within a session. Frequency is how often. Duration is how long the course of treatment runs before it is reassessed.

Two more details from the same section, both of which get missed.

The plan is established before treatment begins, and the occupational therapist who furnishes the services is one of the people who may establish it [1]. You do not need a physician to write it.

Changes to the plan must be made in writing, signed, and "incorporated in the plan immediately" [1]. A verbal decision to drop to once weekly, carried in your head until the next progress note, is a change that has not happened yet.

The Ten Percent Rule That Decides Fifteen Percent of the Payment

This is the sharpest number on the page, and no competing article mentions it exists.

Since 1 January 2020, claims for outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant must include the prescribed modifier. Since 1 January 2022, claims carrying that modifier are paid "an amount equal to 85 percent of the amount of payment otherwise applicable for the service" [2].

So the question of who delivered the minutes is worth fifteen percent. And the threshold is precise:

"'Furnished in whole or in part' means when the occupational therapy assistant either: (A) Furnishes all the minutes of a service exclusive of the occupational therapist; or (B) ... furnishes a portion of a service, or in the case of a 15-minute (or other time interval) timed code, a portion of a unit of service separately from the part furnished by the occupational therapist such that the minutes for that portion ... exceed 10 percent of the total minutes for that service (or unit of a service)." [2]

Ten percent of the minutes decides fifteen percent of the payment.

Which produces a documentation requirement that almost no OT note format includes: minutes have to be recorded by clinician, not only in total. A note that says "45 minutes treatment" cannot answer the question the modifier rule asks.

One exception, stated accurately because it is easy to get wrong. The 10 percent test does not apply when you are deciding whether the modifier attaches to the last 15-minute unit billed on a treatment day, in the case where the therapist provides more than the midpoint of that timed code, meaning 8 or more minutes, regardless of any assistant minutes for the same service [2].

Who Counts as the Therapist and Who Counts as the Assistant

Medicare pays for outpatient occupational therapy only when the services are furnished by someone meeting the qualifications in part 484 for an occupational therapist, or by an appropriately supervised occupational therapy assistant [2].

42 CFR 484.115 defines the occupational therapist as a person who is licensed or otherwise regulated by the state where applicable, graduated from a program accredited by the Accreditation Council for Occupational Therapy Education (ACOTE), and is eligible to take or has passed the national certification examination [3].

That definition is why the minute split matters. These are two distinct credentialed roles, the payment differs between them, and the note is the only record of which one was in the room.

The regulation sets the rule. The operative detail sits one level down, in the Medicare Benefit Policy Manual chapter covering outpatient therapy [4] and in the current billing requirements CMS maintains for therapy services [5]. Both are updated more often than the regulation is, so check them against the year you are billing rather than against a blog post.

The Occupational Therapy SOAP Note Templates

Three blocks. Each is complete as written, so you can paste it straight into a chart.

The Daily Treatment Note Template

OT DAILY TREATMENT NOTE

• Patient, date, setting: (outpatient, inpatient, home, school)

• Treatment start and stop time: (the actual clock times, not the scheduled ones)

• Total treatment minutes: (the sum, separate from the start and stop times)

• Minutes by clinician: (for example "OT 38 min, OTA 7 min" with each person's credentials; this is the line the modifier rule turns on)

• S, Subjective: "(the patient's own words, ideally about performance at home since the last session)"

• O, Objective:(each intervention performed, the occupational performance it targets, the measures taken, and the assist level required)

• A, Assessment: (why this session required the skills of a therapist, and progress against a named goal from the plan)

• P, Plan:(type, amount, frequency and duration, all four named)

• Billing: (each Current Procedural Terminology (CPT) code with its units, and whether the code is timed or untimed; see the documentation requirements that drive coding for how note detail and code selection connect)

• Signature and credentials: (the clinician who furnished the service)

The fourth line is the one almost no template includes and the one that decides the modifier [2]. The Assessment line is the one that decides whether the service reads as skilled.

The Evaluation Note Template

OT EVALUATION NOTE

• Patient, date, referral source, diagnosis: (and the referring clinician)

• Occupational profile: "(what the patient says they need to be able to do, in their words)"

• Prior level of function: (what they could do before, with dates or timeframes where known)

• Measured findings: (each measure paired with the occupational performance it limits)

• Clinical reasoning for skilled need: (why a therapist rather than a home program or an aide)

• Plan of treatment, type: (the specific interventions you will deliver)

• Plan of treatment, amount: (how much within each session)

• Plan of treatment, frequency: (how often per week)

• Plan of treatment, duration: (how many weeks before reassessment)

• Diagnosis and anticipated goals: (the treating diagnosis and what you expect to achieve)

• Plan established by: (name and credentials of the person establishing it, and the date, which may be the occupational therapist furnishing the services)

• Signature and credentials: (the evaluating clinician)

The four Plan lines are separated deliberately. Written as one sentence they collapse back into frequency, which is the failure this whole section is about [1].

The Progress Note Template

OT PROGRESS NOTE

• Patient, reporting period: (the start and end dates the note covers)

• Goals with baseline, current and target: (each goal showing all three numbers, not just current)

• Objective comparison to the last period: (the same measures as last time, with their previous values)

• Response to intervention: (what changed because of what you did)

• Clinical justification: (continue, change or discharge, and why)

• Plan changes: (what changed, the date it was signed, and confirmation it was incorporated into the plan)

• Signature and credentials: (the clinician completing the note)

A progress note whose only difference from the last one is the date is not a progress note. It is a copy with a new header. The same failure shows up in hospice documentation, where an unchanging note actively undermines the record.

Where Sully.ai Fits in Therapy Documentation

Therapy notes get written in the gap between patients, which on a full caseload is about two minutes, or at the end of the day across a stack of sessions.

What erodes first in that gap is anything requiring arithmetic, exactly as it does in shift documentation. Total treatment minutes. Minutes by clinician. Units by code, timed against untimed. None of it is difficult, and all of it is the first thing to become approximate when it is reconstructed six hours later.

Sully.ai's AI scribe for rehabilitation and therapy teams drafts the note from the session and keeps treatment minutes attributed to the clinician who delivered them, so the split is recorded rather than reconstructed. It runs on a single integration across Epic, Cerner, Meditech and Athenahealth.

Two boundaries worth stating plainly.

It does not decide whether the service was skilled. That judgment is the therapist's, and the Assessment field exists to record it. A drafted Assessment that describes what was done rather than why it required a therapist is the most common denial trigger in therapy documentation, and the sentence that fixes it has to come from the person who made the decision.

It cannot resolve a minute split that nobody stated. The modifier question depends on which clinician was present for which minutes. If the session does not make that distinction audible, no tool reading the recording can infer it. The habit of announcing the handoff stays with the clinicians in the room.

Sully operates across 5,000+ providers, has delivered 50M+ hours of work, and prices each role 80 to 90 percent below the human equivalent [6].

Three Worked Examples

An Outpatient Hand Therapy Visit

Post-surgical flexor tendon repair, week 6, outpatient clinic. 1400 to 1445. Total treatment minutes 45. OT 45 min.

S: "I can hold a fork now but I still can't get the lid off anything. My wife has to open the milk."

O: Scar mobilization to volar incision, 8 minutes, addressing adhesion limiting composite flexion. Active and passive range of motion, digits 2 through 5. Composite flexion now 2.5 cm pulp-to-palm distance, was 4 cm on 8 September. Grip strength 18 kg right, 41 kg left uninvolved, which leaves the patient unable to open prescription bottles or turn a house key. Graded functional task practice with jar lids of three diameters, minimal assist required for the largest.

A: Adhesion is responding to mobilization, evidenced by a 1.5 cm gain in pulp-to-palm distance over two weeks. Skilled therapy required for graded scar mobilization and for progression of resistive load within tendon repair protocol precautions, which the patient cannot self-determine. Progress toward goal 2, independent container opening, remains limited by grip strength rather than by range.

P:

• Type: scar mobilization, graded resistive grip strengthening, functional container-opening practice

• Amount: 45 minutes per session

• Frequency: 2x per week

• Duration: 4 weeks, then reassess

Billing: 97140 manual therapy, 1 unit, timed. 97530 therapeutic activities, 2 units, timed.

Every Objective measure is paired with what it stops the patient doing. The Plan names all four elements [1].

A Pediatric School-Based Session

Grade 2, fine motor and self-regulation goals, school setting. 30 minutes. OT 30 min.

S: "My hand gets tired and then my letters go wobbly." Teacher reports the student stops written work after roughly five minutes.

O: Sustained attention to handwriting task 4 minutes before first redirection, was 2 minutes on 4 September. Tripod grasp maintained for 3 of 5 trials, with grasp collapsing to a lateral pinch under fatigue. Completed 2 of 5 lines of copied text independently, which is below the classroom expectation of full-paragraph copying. Trialled a slant board and a weighted pencil; slant board improved grasp maintenance to 5 of 5 trials.

A: Grasp breakdown is fatigue-driven rather than a motor planning deficit, demonstrated by intact grasp in early trials and collapse under load. Skilled therapy required to trial and select adaptive equipment and to grade task demand, which classroom staff are not positioned to do. Progress toward the handwriting endurance goal is measurable at 2 additional minutes over two weeks.

P:

• Type: adaptive equipment trial and training, graded handwriting endurance tasks, teacher consultation on classroom setup

• Amount: 30 minutes per session

• Frequency: 1x per week

• Duration: remainder of the current term, reassessed at the education plan review

A note on setting. School-based practice is usually governed by the student's education plan rather than by Medicare Part B, so the 410.61 elements are not a legal requirement here. They are still the clearest way to write a plan that another therapist can pick up, which is why this example uses them.

A Skilled Nursing Facility Visit With an Assistant

This is the example that carries the point, so the minutes are broken out first.

Skilled nursing facility, 1000 to 1045. Total treatment minutes 45. OT 38 min. OTA 7 min.

S: "I want to get to the bathroom myself. I don't want to ring the bell at night."

O: Bed mobility and sit-to-stand training, supervision level, 20 minutes, delivered by the occupational therapist, with baseline mobility established at the initial assessment. Toilet transfer training with a raised seat, contact guard assist, 18 minutes, delivered by the occupational therapist. Upper body dressing practice, 7 minutes, delivered by the occupational therapy assistant under supervision, with the patient completing the sequence at modified independence.

A: Transfer safety has improved from moderate assist to contact guard over the reporting period, which changes the patient's night-time toileting risk directly. Skilled therapy required for progression of assist level and for equipment selection. Dressing is at modified independence and is appropriate to delegate.

P:

• Type: transfer training, toileting sequence practice, upper body dressing

• Amount: 45 minutes per session

• Frequency: 5x per week

• Duration: 2 weeks, then reassess for discharge planning

Running the threshold. The assistant furnished 7 of 45 total minutes. Seven divided by forty-five is 15.6 percent, which exceeds 10 percent, so the service counts as furnished in part by the assistant and the prescribed modifier applies [2].

Note what made that calculation possible. Not the total. The fourth line of the note.

What Gets an OT Note Denied

A Plan field that names frequency only. "Continue 2x/week" supplies one of the six elements the regulation lists [1]. Name the type, the amount and the duration alongside it.

An Assessment that describes instead of reasons. "Patient tolerated treatment well" says what happened. It does not say why the session required a therapist, which is the question being asked.

Total minutes with no clinician attribution. A note that records 45 minutes and nothing else cannot support or refute the modifier decision [2].

A progress note identical to the last one. If the measures, the goals and the justification are unchanged, the note is evidence that nothing is happening.

FAQ

What goes in the plan section of an occupational therapy SOAP note?

For Medicare Part B outpatient occupational therapy, four things about the service plus two more. 42 CFR 410.61 requires the written plan of treatment to prescribe the type, amount, frequency and duration of the services, and to indicate the diagnosis and anticipated goals [1]. A Plan field reading "continue 2x/week" supplies frequency and omits the rest.

How do you write the objective section of an OT SOAP note?

Record what you measured and observed during the session, and pair every impairment measure with the occupational performance it limits. Grip strength on its own documents an impairment. Grip strength recorded alongside the fact that the patient cannot open a prescription bottle documents occupational therapy.

What is the occupational therapy assistant modifier?

Since 1 January 2020, claims for outpatient occupational therapy furnished in whole or in part by an occupational therapy assistant must include the prescribed modifier, and since 1 January 2022 those claims are paid at 85 percent of the amount otherwise applicable [2]. That is why treatment minutes need recording by clinician rather than only as a total.

What counts as "in part" for the assistant modifier?

The assistant either furnishes all the minutes of a service without the therapist, or furnishes a portion such that the assistant's minutes exceed 10 percent of the total minutes for that service or unit [2]. One exception applies to the last 15-minute unit billed on a treatment day where the therapist provides 8 or more minutes of that timed code [2].

Can an AI scribe write occupational therapy SOAP notes?

It can draft them from the session, including the objective findings and the patient's own words, and Sully.ai keeps treatment minutes attributed to the clinician who delivered them. What it cannot do is decide whether the service required the skills of a therapist, any more than it can write the clinical reasoning in a therapy note. That reasoning belongs in the Assessment field, and it belongs to the therapist.

Sources

[1] U.S. Government Publishing Office — 42 CFR 410.61, Plan of treatment requirements for outpatient rehabilitation services. https://www.govinfo.gov/content/pkg/CFR-2023-title42-vol2/xml/CFR-2023-title42-vol2-sec410-61.xml

[2] U.S. Government Publishing Office — 42 CFR 410.59, Outpatient occupational therapy services: Conditions. https://www.govinfo.gov/content/pkg/CFR-2023-title42-vol2/xml/CFR-2023-title42-vol2-sec410-59.xml

[3] U.S. Government Publishing Office — 42 CFR 484.115, Condition of participation: Personnel qualifications. https://www.govinfo.gov/content/pkg/CFR-2023-title42-vol5/xml/CFR-2023-title42-vol5-sec484-115.xml

[4] Centers for Medicare & Medicaid Services — Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/bp102c15.pdf

[5] Centers for Medicare & Medicaid Services — Therapy Services. https://www.cms.gov/medicare/billing/therapyservices

[6] Sully.ai — AI Medical Scribe. https://www.sully.ai/medical-scribe