An introduction to SOAP notes
SOAP notes are a widely used clinical documentation format that allows healthcare professionals and clinicians to capture client information. With the SOAP format, practitioners can ensure valuable information is presented in a way that is easy to interpret and be understood by others. Using progress notes, healthcare professionals can assess patients and their current condition through a subjective and objective lens to provide the best care. A SOAP note format analysis can contribute to collecting systematic electronic health records within the healthcare sector. Assessing the patient through SOAP enables the formulation of an effective treatment plan and allows for any current treatment to be reviewed. This makes SOAP a great way to organize and structure your clinical records and effectively convey patient information.
What should be included in a SOAP note?
To create practical SOAP notes, multiple aspects need to be included, including the four main components. To simplify this, we have summarized the core factors:
- Subjective (S) - This section focuses on the experience of the client, as well as understanding their perception. Subjective notes, including verbatim quotes, help paint a picture of the patient’s feelings, symptoms, and progress towards treatment goals.
- Objective (O) refers to the practitioner’s observations concerning the patient’s medical information, evaluations, tests, x-rays, historical information, medication, and vital signs. It is factually based, free from any clinician impressions.
- Assessment (A) - This summarizes the subjective and objective sections and is a directional section that focuses on progress towards a treatment plan. It evaluates how the client is doing in their current state and notes their diagnosis as it is and any changes. All of which are used in the next section.
- Plan (P) - The final section of SOAP notes is to derive a treatment plan based on the client’s previous observations and current treatment plan or state. A course of action, with measurable goals specifically listed, is finalized to treat the patient.
SOAP Note: Basic template with example
To help you better understand SOAP notes, a free basic template has been produced with an integrated SOAP notes example.
What does the S stand for in SOAP notes?
The subjective (S) section focuses on the client’s experience and emphasizes their feelings, needs, and perception of their symptoms. The best way to capture this is to include verbatim quotes of the patient, with their exact wording, so as not to misinform other healthcare professionals who may review the notes. Subjectivity allows clinicians to compile a firsthand document of what the client would like to achieve based on their current state and enables fellow contacts to comment if needed. It provides a clear picture that represents the client’s experience and reduces the risk of miscommunication with the prohibition of paraphrasing and making statements without primary evidence.
A SOAP notes template of the subjective section may look like this:
Maia states that she is “feeling okay; some days are better than others.” Her depressive symptoms fluctuate but seem to be improving. Maia indicates that she still feels down, stating, “When I do feel low, it’s more of a flat feeling, and I can now get myself out of it a little bit.” She explains that her main concern at the moment is sleeping, as she only sleeps “for around 5 hours a night.”
What does the O stand for in SOAP notes?
The goal of the objective (O) section is to focus on factual observations of the client. This mainly concerns quantifiable measurements and evaluations, assessments, tests, x-rays, medical or medication information, or noting of relevant vital signs. Typically, the objective statement is used to provide evidence for symptoms, rather than relying on the experience of the symptoms by the client. What is observed could contradict or confirm information seen in the subjective section but is used to aid clinicians in developing a treatment plan based on fact.
An example of the objective section:
Maia presented an upbeat demeanor. Her mood appears to be relatively stable, which is an improvement from the last session. Her voice expresses more variation, with a mildly reduced flat affect, and she seems to regulate her mood better. This is all despite her appearance, which indicates fatigue. Her sleep patterns are also disrupted based on her sleep tracking data.
What does the A stand for in SOAP notes?
The assessment (A) section provides a synthesis of both the subjective and objective sections to work towards an effective treatment plan. Assessment allows for a general commentary on the client's state and evaluates prior evidence to provide a clear picture of a definite diagnosis and care plan. Its systematic nature means that any underlying issues can be identified and enables a big-picture perspective of how the client is doing with their available resources. It provides clinicians the opportunity and starting point to think of alternate ways to help patients through a comprehensive evaluation of their state. This assessment is relatively straightforward with more commonplace psychological issues, whereas, with others with high comorbidity, this may take longer.
A focused SOAP note example of the assessment section is provided here, which can be incorporated within this free SOAP note template:
Maia has Major Depressive Disorder (MDD) and has a family history. She seems to respond well to current therapy and medication of 20 mg of sertraline once per day, improving symptoms from last week.
What does the P stand for in SOAP notes?
The final plan (P) section is where the assessment and analysis of observations come together to define the next course of action for the patient. The plan establishes a direction for the patient and either amends the current treatment plan or creates a new one that addresses their identified healthcare issues. This could involve changing medication, activity, or overall goals. It is helpful to include the rationale behind the currently administered treatment, the patient’s response, and when the next session will be. To encourage productivity, it is also essential that the plan section incorporates specific goals to present a clear plan to the client.
An example of the plan section:
Maia will continue to attend therapy next week as usual, and she will continue with her 20 mg of sertraline medication once per day. If symptoms do not improve within the next two weeks, we will reevaluate her options to increase the dose or use alternative medicines. I have worked through a sleep schedule plan with her, and if this does not improve within the next two weeks, we will assess prescribing medication to alleviate this issue.
Example of a basic SOAP Note Template
Example of a psychotherapy SOAP note
Further example of SOAP note template
Common FAQs about SOAP notes
Are SOAP notes still used?
With the rise of technology being used in the healthcare industry, handwriting clinical documentation has largely gone out of fashion. However, that’s not to say that the SOAP format itself isn’t still commonly used. Given how effective SOAP notes are at simplifying documentation and ensuring both consistency and accuracy, they are very much still in use - and this isn’t going to change anytime soon.
Where do medications go in a SOAP note?
Generally, a patient’s medications should be listed in the subjective section of the SOAP note. It may be necessary to write whether the client has been compliant or noncompliant with their medication. On the other hand, if you perceive the medication to be effective for the client’s condition, you may want to record this in the assessment section. It can be quite difficult to distinctly separate different components into the four SOAP sections, and a lot of how you record the information will come down to professional preference. As long as you write down the right amount of information in a clear and concise way, your documentation should be fine.
How many pages should a SOAP note be?
SOAP notes should always be as concise as possible. That being said, you don’t want to miss recording any important information. While the length of a SOAP note will be largely dependent on the individual session and the patient’s needs, you will likely want to aim for somewhere between 1-2 pages.
What is the advantage of using SOAP notes?
There are a vast abundance of advantages when it comes to using SOAP notes. Every healthcare practitioner knows how important keeping accurate clinical documentation is, and utilizing the SOAP note format is one of the best (and easiest) ways to improve your documentation. SOAP notes guarantee consistency and accuracy across your records. Given that documentation is often shared between a patient’s care providers, this type of organization will make it much easier to locate relevant information and improve coordination of care. Lastly, using the SOAP format has advantages for clinicians: there are many useful templates available for practitioner use, saving you a lot of time and enabling you to do what you do best - help your patients.
What is the difference between SOAP note and Progress note?
Essentially, a SOAP note is a type of progress note. Progress notes are a broader term that refers to a particular component of clinical documentation. In order to make the process of documentation simpler for clinicians, different formats (including SOAP) have been created.
Harnessing SOAP notes in the healthcare space
Because of its user-friendly format, which touches on all necessary aspects of clinical documentation, SOAP notes are widely used and recognized in the healthcare industry. They are an excellent method of being easy to understand with clear formatting and are also easy to interpret by other healthcare professionals due to their professional approach. The process from observation to the formulation of a treatment plan is highly transparent and offers significant value to practices that use them. It allows for compliance of medical professionals in the case of law and ethics, with their transferable structure, and is a perfect option in healthcare business management.
Many platforms, such as Carepatron, actually incorporate SOAP notes templates into their workflow, which makes switching to this universal documentation method all the more beneficial. Embedded SOAP templates mean your practice can seamlessly integrate them into your clinical space, with a clean user interface allowing for an easy learning experience. Carepatron is a great starting place for delving into SOAP notes and working towards providing the best care for your patients.
One SOAP note app for practitioners and their clients: Try Carepatron for free today!
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