Reflective Journal: First Community Placement SOAP Note Experience

This assignment is a reflective journal written by an occupational therapy student detailing their first experience with SOAP notes during a community placement. Utilizing Gibb's reflective model, the student describes their initial experiences, including working with diverse patients and the challenges of writing SOAP notes due to grammatical issues and new terminology. The journal explores mixed feelings of anxiety and excitement, evaluating the need for improved documentation and knowledge. The analysis highlights the importance of SOAP notes in clinical reasoning and communication, referencing professional standards and codes of ethics. The conclusion emphasizes the need for further patient assessment practice and improved SOAP writing skills, culminating in an action plan involving mentorship, online learning, and feedback to enhance future performance.

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

2SOAP REFLECTIVE
addition it was difficult for me to remember various new terms related to patient assessment,
functional difficulties and occupation therapy.
On evaluating my experience, I found I need to improve my documentation skills and
knowledge. Placement was effecting in learning my strengths and weakness. As per the code of
ethics, section 2 on service provision, the factors central to the occupational performance are
“assessments, interventions, outcomes and documentation” (Pearmain 2010). As per Gateley and
Borcherding (2012) being competent in SOAP framework, is important as keeping tool is the
standard note in public health setting. Physicians can well understand the patient’s function if the
SOAP notes are logical, clear and concise (Gateley and Borcherding 2012). On analysis, I found
SOAP useful in improving my clinical reasoning skills as it helps to analyse the situation. As per
the HCPC Standards of proficiency 2013, effective communication is important. I need to
improve my verbal and written skills. I needed more in-depth knowledge and skills related to
occupational therapy. HCPC standards emphasise on keeping records of work accurately and
clear (Health and Care Professions Council 2012).
It can be concluded from the reflection that I need to engage more in patient assessment
to be able to work independently. I need to improve my skills of writing SOAP to get accurate
records in future. Therefore, my action plan for future performance is to engage with seniors
and mentors to learn effective SOAP writing. To improve patient’s assessment skill, I will take
online learning program and learn from online videos. I will take feedback from my educators to
evaluate the outcomes.

3SOAP REFLECTIVE
References
Clark, G.F. and Youngstrom, M.J., 2013. Guidelines for documentation of occupational
therapy. The American Journal of Occupational Therapy, 67(6), p.S32.
Gateley, C.A. and Borcherding, S., 2012. Documentation manual for occupational therapy:
Writing SOAP notes. Slack.
Health and Care Professions Council, 2012. Guidance on conduct and ethics for students. HCPC.
Pearmain, H., 2010. Code of ethics and professional conduct. College of Occupational
Therapists. London: College of Occupational Therapists Ltd. Retrieved July, 11, p.2011.