Reflection on First Experience with SOAP Notes in Occupational Therapy

Running head: SOAP REFLECTIVE
SOAP reflective
Name of the Student
Name of the University
Author note

1SOAP REFLECTIVE
In health care accurate professional documentation is necessary to foster the quality of
care as well as its continuity. It is useful in creating effective communication between providers
and other members about preventive health services, health status, care plan, delivery of
treatment and planning (Clark and Youngstrom 2013). This assignment is the reflection of the
first experience with SOAP notes, when placed in the community for the first time in the
community as a part time of the occupational therapy. For the purpose of reflection, Gibb’s
reflective model is used that consists of the stages description, feelings, evaluation, analysis,
conclusion, and action plan.
To describe my first placement in community as a student of occupational therapy, I have
learnt more than it was imaginable. I had to work with diverse patients, those with dementia,
fatigue, had fallen and others. My role was to ensure that the patients can have safe discharge
and access their chosen occupation. I was well supported by mentor and gave me clear
instructions on wiring SOAP notes. I had great struggle writing these notes. It is important as it
will be used by other members to proceed with the care plan. I had to carefully observe my
mentor during initial assessment of the patients such as ADL’s assessment. It is required to asses
if there is need of any occupational therapy equipment for the patients. I had difficulty in writing
SOAP notes due to grammatical issues.
I had mixed feelings during this placement. I had anxiety in writing my SOAP notes. At
the same time I was excited in learning holistic approach in patient assessment. I was inquisitive
at the start of the placement and ended with list of things that I needed to improve to deliver high
quality care. I was unsatisfied with my SOAP notes as they were not legible due to grammatical
errors. I was nervous while performing the duties of care as I found SOAP notes hard. In