SOAP notes are a helpful method of documentation designed to assist medical professionals in streamlining their client notes. Using a template such as SOAP note means that you can capture, store and interpret your client's information consistently, over time.
You probably already know this, but SOAP is an acronym that stands for subjective, objective, assessment, and plan. Each letter refers to the different components of a soap note and helps outline the information you need to include and where to put it.
Even though SOAP notes are a simple way to record your progress notes, it's still helpful to have an example or template to use. That's why we've taken the time to collate some examples and SOAP note templates we think will help you to write more detailed and concise SOAP notes.
Subjective (S): The client's perspective regarding their experience and perceptions of symptoms, needs, and progress toward treatment goals. This section often includes direct quotes from the client/ patient as well as vital signs and other physical data.
Objective (O): Your observed perspective as the practitioner, i.e., objective data ("facts") regarding the client, like elements of a mental status exam or other screening tools, historical information, medications prescribed, x-rays results, or vital signs.
Assessment (A): Your clinical assessment of the available subjective and objective information. The assessment summarizes the client's status and progress toward measurable treatment plan goals.
Plan (P): The actions that the client and the practitioner have agreed upon to be taken due to the clinician's assessment of the client's current status, such as assessments, follow‐up activities, referrals, and changes in the treatment.
As helpful as SOAP notes outline what details are required and how to layout any progress notes, it can be beneficial to have an example in front of you. That's why we've taken the time to collate some exemplars and SOAP note templates we think will help you to write more detailed and concise SOAP notes.
John reports that he is feeling 'tired' and that he 'can't seem to get out of bed in the morning.' John is 'struggling to get to work' and says that he 'constantly finds his mind wondering to negative thoughts.' John stated that his sleep had been broken and he does not wake feeling rested. He reports that he does not feel as though the medication is making any difference and thinks he is getting worse.
John was unable to come into the practice and so has been seen at home. John's personal hygiene does not appear to be intact; he was unshaven and dressed in track pants and a hooded jumper which is unusual as he typically takes excellent care in his appearance. John appears to be tired; he is pale in complexion and has large circles under his eyes.
John's compliance with his new medication is good, and he appears to have retained his food intake. Weight is stable and unchanged.
John presented this morning with low mood and affect. John exhibited speech that was slowed in rate, reduced in volume. His articulation was coherent, and his language skills were intact. His body posture and effect conveyed a depressed mood. John's facial expression and demeanor were of someone who is experiencing major depression. Affect is appropriate and congruent with mood. There are no visible signs of delusions, bizarre behaviors, hallucinations, or any other symptoms of psychotic process. Associations are intact, thinking is logical, and thought content appears to be congruent. Suicidal ideation is denied. Short and long-term memory is intact, as is the ability to abstract and do arithmetic calculations. Insight and judgment are good. No sign of substance use was present.
Diagnoses: The diagnoses are based on available information and may change as additional information becomes available.
Major depressive disorder, recurrent, severe F33.1 (ICD-10) Active
Link to treatment Plan Problem: Depressed Mood
Problem: Depressed Mood
John's depressed mood has been identified as an active problem requiring ongoing treatment. It is primarily evident through a diagnosis of Major Depressive Disorder.
John will develop the ability to recognize and manage his depression.
Short-term goals and interventions
- continue to attend weekly sessions with myself
- continue to titrate up SSRI, fluoxetine
- to walk Jingo once a day
- to use a safety plan if required
Stacey reports that she is 'feeling good' and enjoying her time away. Stacey reports she has been compliant with her medication and using her meditation app whenever she feels her anxiety.
Stacey was unable to attend her session as she is on a family holiday this week. She was able to touch base with me over the phone and was willing and able to make the phone call at the set time. Stacey appeared to be calm and positive over the phone.
Stacey presented this afternoon with a relaxed mood. Her speech was normal in rate, tone, and volume. Stacey was able to articulate her thoughts and feelings coherently.
Stacey did not present with any signs of hallucinations or delusions. Insight and judgment are good. No sign of substance use was present.
Plan to meet again in person at 2 pm next Tuesday, 25th May. Stacey will continue on her current medication and has given her family copies of her safety plan should she need it.
Mrs. Jones states that Julia is "doing okay." Mrs. Jones said her daughter seems to be engaging with other children in her class. Mrs. Jones said Julia is still struggling to get to sleep and that "she may need to recommence the magnesium." Despite this, Mrs. Jones states she is "not too concerned about Julia's depressive symptomology.
Mrs. Jones thinks Julia's condition has improved.
Julia will require ongoing treatment.
Plan to meet with Julia and Mrs. Jones next week to review mx. To continue to meet with Julia.
Martin has had several setbacks, and his condition has worsened. Martin reports that the depressive symptoms continue to worsen for him. He feels that they are 'more frequent and more intense. Depressive symptomology is chronically present. He expressed that he has experienced no change in anhedonia and his energy levels are lower than they have been in the past month. He states that he now constantly feels fatigued both mentally and physically. Martin finds concentrating difficult, and that he quickly becomes irritated. Feelings of worthlessness and self-loathing are described. Martin describes experiencing suicidal ideation daily but that he has no plan or intent to act.
Martin denies any hallucinations, delusions, or other psychotic-related symptomology. His compliance with medication is good. He appears to have gained better control over his impulsive behavior as they are being observed less frequently. Martin appears to have lost weight and reports a diminished interest in food and a decreased intake.
The therapeutic focus of this session was to ascertain the severity of Martin's ongoing depression and help Martin increase his insight and understanding of his depression. The content of the therapy was to focus on coping with depression and tools that can be used to enable Martin to make progress.
Martin presents as listless, distracted, and minimally communicative. He exhibits speech that is normal in rate, volume and articulation is coherent and spontaneous. Language skills are intact. There are signs of severe depression. Body posture, eye contact, and attitude portray a depressed mood. The slowness of physical movement helps reveal depressive symptomology. There are no apparent signs of hallucinations, delusions, or any other indicators of psychotic processes. Associations are intact, and thinking is logical. He appears to have good insight. The thought process seems to be intact, and Martin is fully orientated. Martin describes experiencing suicidal ideation daily but that he has no plan or intent to act. Martin's behavior in this session was cooperative and attentive.
Martin continues to require outpatient treatment. He consistently exhibits symptoms of major depressive disorder, and which interfere with his day-to-day functioning and requires ongoing treatment and support.
1. Meet with Martin again in 2 days, Friday, 20th May
2. Martin to follow his safety plan if required
3. Martin to make his family aware of his current state of mind
Ms. M. states that she is "doing okay." Ms. M. states that her depressive symptomatology has improved slightly; she still feels perpetually "sad." Ms. M. states her sleep patterns are still troubled, but her "sleep quality is improving" and getting "4 hours sleep per night" She expresses concern with my note-taking, causing her to be anxious during the session. She also is worried about experiencing occasional shortness of breath. She also states that "healthcare providers make her anxious and wants to know where her medical records are being kept."
Ms. M. is alert. Her mood is unstable but improved slightly, and she is improving her ability to regulate her emotions.
Ms. M. has a major depressive disorder.
Ms. M. will continue taking 20 milligrams of sertraline per day. If her symptoms do not improve in two weeks, the clinician will consider titrating the dose up to 40 mg. Ms. M. will continue outpatient counseling and patient education and handout. Comprehensive assessment and plan to be completed by Ms. M's case manager.
The SOAP note could include data such as Ms. M vital signs, patient's chart, HPI, and lab work under the Objective section to monitor his medication's effects.
"I'm tired of being overlooked for promotions. I don't know how to make them see what I can do." Frasier's chief complaint is feeling "misunderstood" by her colleagues.
Frasier is seated, her posture is rigid, eye contact is minimal. Frasier appears to be presented with a differential diagnosis.
Assessment of Progress
Frasier is seeking practical ways of communicating her needs to her boss, asking for more responsibility, and how she could track her contributions.
Plans for Next Session
Book in for a follow-up appointment. Work through some strategies to overcome communication difficulties and lack of insight. Request GP or other appropriate healthcare professionals to conduct a physical examination.
David states that he continues to experience cravings for heroin. He desperately wants to drop out of his methadone program and revert to what he was doing. David is motivated to stay sober by his daughter and states that he is "sober, but still experiencing terrible withdrawals" He stated that [he] "dreams about heroin all the time, and constantly wakes in the night drenched in sweat."
David was prompt to his appointment; he filled out his patient information sheet quietly in the waiting room and pleasant during the session. He did not display signs of being under the influence. David remains aroused and distractible, but his concentration has improved. This was indicated through his discussion with me about his partner for fifteen minutes and his ability to reflect on his history. David's personal hygiene and self-care have markedly improved. His physical exam report demonstrated that he had gained 3pounds.
David is making significant progress. He applies skills such as control techniques, exercises and he is progressing in his treatment. His cravings have reduced from "constant" to "a few times an hour." David continues to experience regular cravings with a 5-year history of heroin use. David needs to acquire and employ additional coping skills to stay on the same path. David is doing well, but there is significant clinical reasoning to state that David would benefit from CBT treatment as well as extended methadone treatment.
David has received a significant amount of psychoeducation within his therapy session. The therapist will begin to use dialectical behavioral therapy techniques to address David's emotion dysregulation. David also agreed to continue to hold family therapy sessions with his wife. Staff will continue to monitor David regularly in the interest of patient care and his past medical history.
Ruby stated that she feels 'energized' and 'happy.' She states that getting out of bed in the morning is markedly easier and she feels 'motivated to find work.' She has also stated that her 'eating and sleeping has improved,' but that she is concerned, she is 'overeating.'
Ruby attended her session and was dressed in a matching pink tracksuit. Her personal hygiene was good, and she had taken great care to apply her makeup and paint her nails. Ruby appeared fresh and lively. Her compliance with her medication is good, and she has been able to complete her jobseekers form.
Ruby presented this morning with markedly improved affect and mood. Her speech was normal in rate and pitch and appeared to flow easily. Her thoughts were coherent, and her conversation was appropriate. Ruby's appearance and posture were different from what they were in our last session. Ruby's medication appears to be assisting her mental health significantly.
Ruby to see me again in one week
Ruby to contact me if she requires any assistance in her job seeker process
Ruby to continue on her medication
Dr. Smith and I to review this new pertinent information in MDT and discuss possible diagnoses we had considered
Chief complaint: 56-year-old female presents with a "painful upper right back jaw for the past week or so"
History of Present Illness: historically asymptomatic
Medical conditions: Nil.
Social History: Tobacco, ETOH
Vitals: BP 133/91 HR: 87 Temp: 98.7
Extraoral (Swelling, Asymmetry, Pain, Erythema, Paraesthesia, TMI):
Intraoral (Exudate, Erythema, Hemorrhage, Occlusion, Pain, Biotype, Hard Tissue, Swelling, Mobility):
#17 (FDI #27) Supra erupted and occuding on pericoronal tissues of #16
#16 Partially erupted, erythematous gingival tissue, exudate, pain to palpate
Radiology (PA Pano, CT):
1. Smoker (1 pack per week)
2. #17 supraerupted and occluding on opposing gingiva
3. #16 Pericoronitis
1. Extraction #17 today
2. Antibiotics (10-day course of penicillin)
3. Follow up (pm)
Jenny's mother stated, "Jenny's teacher can understand her better now" Jenny's mother is "stoked with Jenny's progress" and can "see the improvement is helpful for Jenny's confidence."
Jenny was able to produce /I/ in the final position of words with 80% accuracy.
Jenny's pronunciation has improved 20% since the last session with visual cues of tongue placement. Jenny has made marked improvements throughout the previous 3 sessions.
Jenny continues to improve with /I/ in the final position and is reaching the goal of /I/ in the initial position. Our next session will focus on discharge.
Example 11. Physical Therapy Progress Note
At the time of the initial assessment, Bobby complained of dull aching in his upper back at the level of 3-4 on a scale of 10. Bobby stated that the "pain increases at the end of the day to a 6 or 7". Bobby confirmed he uses heat at home and finds that a "heat pack helps a lot."
The cervical spine range of motion is within functional limit with pain to the upper thoracic with flexion and extension. Cervical spine strength is 4/5. The right lateral upper extremity range of motion is within the functional limit, and strength is 5/5. Palpation is positive over paraspinal muscles at the level of C6 through to T4, with the right side being less than the left. The sensation is within normal limits.
Bobby is suffering from pain in the upper thoracic back.
To meet with Bobby on a weekly basis for modalities, including moist heat packs, ultrasound, and therapeutic exercises. The goal will be to decrease pain to a 0 and improve functionality.
Darleene is 66 y/o who attended her follow-up of her HTN. She feels well. She does not have dizziness, headache, or fatigue.
Darleene has no history other than hypertension. Her only medication is HCTZ at 25mg per day. Darleene has lost 53bs in the past 3 months, following a low-fat diet and walking 10 minutes a day. She drinks two glasses of wine each evening. Darleene uses no OTC medications such as cold remedies or herbal remedies.
Generally, Darleene appears well. Weight 155lbs, Height 55 inches, BMI ~30, Pulse 76 reg, BP 153/80. She has no lower extremity edema.
Darleene is here for a follow-up of her hypertension. It is not well-controlled since blood pressure above the goal of 135/85. A possible trigger to her poor control of HTN may be her alcohol use or the presence of obesity.
- Continue a low-fat diet and exercise. Consider increasing walking time to 20-30 minutes to assist with weight loss.
- Discussed alcohol use and its relationship to HTN. Darleene agrees to a trial of drinking wine only on weekend evenings.
- Check home BPs.
- Check potassium since she is taking a diuretic.
- Follow-up in the clinic in 1 month. Bring a blood pressure diary to that visit. Consider adding ACE inhibitor at next visit if BP is still elevated.
Fred stated that it had been about one month since his last treatment. Fred stated that he "has been spending a lot more time on his computer" and attributes his increased tension in his upper back and neck to this. Currently, Fred experiences a dull aching 4/10 in his left trapezius area. He "would like a relaxation massage with a focus on my neck and shoulders."
Tenderness at the left superior angle of the scapula. Gross BUE and cervical strength. A full body massage was provided. TrPs at right upper traps and scapula. Provided client with education on posture when at the computer. Issued handouts and instructed on exercises. All treatment kept within Pt.
Fred reported 1/10 pain following treatment. Good understanding, return demonstration of stretches and exercises—no adverse reactions to treatment.
To continue DT and TRP work on upper back and neck as required. Reassess posture and sitting at the next visit.
Okay, now we know everything there is to know about SOAP notes.
They're helpful because they give you a simple method to capture your patient information fast and consistently.
Take a look at the SOAP note examples we listed here to determine which one fits your needs and profession best.
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