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February 11, 2022

Ultimate Guide to SOAP Notes

Ultimate Guide to SOAP Notes

Ultimate Guide to SOAP Notes

SOAP notes are one of the most widely used clinical documentation formats, that allows clinicians and healthcare professionals to capture medically rich information from patients. With SOAP notes, fellow healthcare practitioners can easily interpret notes and documents, and use the information to generate valuable insights to improve clinical outcomes and treatments. We acknowledge that it can feel overwhelming to learn and abide by good progress note practices, and so we’re here to help! To consolidate your understanding when it comes to SOAP notes, and to help provide the highest quality of care when it comes to your patients, we have collated some of the top tips within this ultimate guide. 

The Basics

What is a SOAP note?

SOAP notes, in their purest form, are a specific way of writing progress notes to record client medical information that can be used for treatment plans and to alleviate clinical diagnoses. They are an excellent way to organize valuable information, in a way that can be effectively used by other healthcare professionals, and insurance providers for medical reimbursement. SOAP notes support a specific note structure that ensures high-quality notes, conciseness, and relevance. As a universal planning aspect, they can be used by people in virtually any healthcare discipline, and as a result, they are one of the leading options for progress notes. 

Writing a SOAP note

What is a progress note?

Naturally, you may be wondering what a progress note is, and this is a good question! In order to understand the purpose of SOAP notes, you must first understand what progress notes are. Fortunately, progress notes really are as simple as they sound. Progress notes are part of what makes up medical records, where practitioners record client medical information pertaining to their medical experience. This means that patient symptoms are recorded, diagnoses, as well as medical evidence, results, and tests, and how this all works towards treatment plans. Essentially, progress notes provide a paper trail of how recorded symptoms can morph into effective treatments that prioritize patient needs, which is also highly important for fulfilling legal obligations. Healthcare professionals must be held accountable for their medical actions, and must demonstrate clinical reasoning, with progress notes providing a record of events that examine different health statuses. When it comes to peer review and assessment, all healthcare clinicians must be able to read the content and agree with its material, with it noting accurate and factual information. Progress notes can have various different formats, and SOAP notes are one of the most common. 

Why are SOAP notes important?

SOAP notes are highly significant and are a driving factor for the success of healthcare practices. There are a variety of reasons why SOAP notes are essential for health businesses to thrive, and to simplify this for you, we have compiled four essential reasons as to why they are important for your practice. 

  1. Tracks progress - SOAP notes are vital for tracking the progress of your patient’s health, and whether they are making improvements with the current treatment administered to them. Despite how many appointments the patient sees, fellow healthcare practitioners simply have to assess the SOAP note, and evaluate changes in the patient’s health status. 
  2. Foster strong communication - SOAP notes present a concise summary of health insights, tests, and assessments, meaning that across all healthcare practices, health professionals can easily understand the patient’s health. All information is up to date, and recorded with high accuracy to ensure that essential details are effectively communicated.
  3. Fulfill legal obligations - In the case of malpractice, or if a patient’s health condition becomes involved with legal issues, SOAP notes are an excellent way to protect you and your staff, as it provides primary evidence with clinical reasoning. This can be used in legal cases, and also ensures that you remain and uphold compliance, to avoid costly consequences. 
  4. Insurance -  Having accurate clinical documents with SOAP notes means your practice can receive reimbursement, as your medical billing and coding services are more likely to be accurate. 
SOAP notes are important

What does SOAP stand for?

SOAP notes consist of four sections, which include subjective, objective, assessment, and plan. It is the requirement for a progress note to be classified as a SOAP one, as it must follow this structure and cover all four bases. 

Subjective: 

This section captures patient information based on their unique experience, and aims to focus on their needs and symptoms. Typically, the subjective passage includes direct quotes to explicitly convey the patient experience, and ensure that information is straightforward and not misconstrued or misinterpreted. Fellow healthcare professionals who review the clinical notes can also be properly informed, understand the patient’s experience through a firsthand account, and help document what the patient actually feels. Within this section, family members and other close contacts can also comment on the patient to provide a more clarified picture of their experience. 

Practitioners who review and assess this information can also have richer insight concerning the patient’s symptoms and treatment progress, with it allowing a more authentic experience. As a result, because of subjectivity, you mustn’t paraphrase, make assumptions without evidence, and this section should be strictly guided by primary evidence. The patient should lead what is written, and how it is impacting their day-to-day life. 

Objective:

This section is solely concerned with factual observations and measurements that are able to be quantified. As a result, this means medical information and data such as assessments, tests, vital signs, such as blood pressure, height, and weight, x-ray results, and exams are also included. All healthcare professionals should be able to conduct the same results and receive the same outcome, as it is scientifically based. There should be no general statements or assumptions without supporting evidence, and there should be subjective observations listed. 

It is important to distinguish between describing facts and noting observations concerning the symptoms shown in a patient, as sometimes these are confused when it comes to writing objective notes. Symptoms are the patient’s experience of a condition, whereas the signs are objective observations of symptoms. What is recorded may contradict what is stated in the subjective section, however, this still needs to be included for a more inclusive and holistic treatment. 

Assessment:

In this section, healthcare practitioners can work towards combining subjective and objective information to work towards effective treatment that alleviates pain and symptoms. It serves to comment on the current state of a patient’s health, and synthesizes evidence in hopes to support more accurate representations of a diagnosis. The assessment section systematically analyzes the patient experience to identify root causes and underlying issues, in order to work towards higher clinical outcomes and treatments. 

This is usually straightforward in assessing patients, however, for some disorders that have high comorbidity rates, this process is likely to take longer. However, this should be of no concern, as treatment is one of the most important parts of healthcare, and you should take time when assessing patients to note how they are doing with their current resources. This means including any information concerning changes with their progress, medication, or current treatment response, so you can also ensure that the assessment accurately reflects the patient’s current state. All assessment information should be professionally represented, with minimal repetition, and no irrelevant information. 

Plan:

In this final section, the analysis of observations and assessment should be collected to effectively define and plan the next course of action pertaining to the patient’s diagnosis. This is a directional step, and should work towards alleviating pains, minimizing symptoms, and accomplishing healthcare goals. In many cases, this may mean simply amending the current treatment plan of the patient, and adjusting to new developments concerning symptoms. However, this could also mean creating a new treatment plan that accommodates any changes, and can more accurately treat the patient’s condition. Treatment plans could entail general goals, activity recommendations, as well as any medication prescriptions. 

Whatever plan you decide on, it’s important that you provide the medical reasoning and rationale behind your choice. This way, when other healthcare professionals review your material, they can easily understand the line of thinking that led to your decision, and can work with the information given. Plans should incorporate a specific set of steps in regards to treatment, so the patient knows when their next session is, and the tasks they need to work on in the meantime. It’s useful for clients to be able to be productive towards their goals and treatment, in knowing exactly what they need to do, and it’s also useful for you as the practitioner to have a clearer direction for your client treatments. 

SOAP Note success

Within these sections, you should also include the following:

  • Patient name
  • Date
  • Time
  • Signature of practitioner that is orchestrating the appointment
  • Diagnosis and symptoms
  • Location of session
  • Any test results
  • Patient information concerning their presentation

SOAP Notes Scope + Examples

SOAP notes are an excellent tool for a variety of healthcare professionals, across a variety of specialties. It’s not exclusive to any particular area of expertise, and can cater to a variety of professionals, including the following. 

Occupational Therapy

SOAP notes are great for occupational therapy, as they allow for mobility limitations and improvements to be noted, as well as evidence of exercises performed each week. Creating plans is highly effective under this area of expertise, as patients can work on particular strengthening exercises throughout the time between their next appointment, which can be quantifiably examined and improved with each session. 

A SOAP note for occupational therapy may look like the following:

Subjective

Julie states she has been having knee pain, rating it a “3/10” following her fall a few days ago. She states she has increased radiating symptoms in her knee and has been taking ibuprofen and panadol to manage it. 

Objective

Julie has been having improvements in her pain and mobility with the following exercises of partial squats (3x10), hamstring stretch in standing step (3x40 sec), and standing up to 9” surface x 20 reps. 

Assessment

Julie has made solid improvements in her mobility following her regular exercises, which are shown today. Because some activities, such as stairs, remain somewhat difficult for her, and single-leg stability is 6 seconds, she would benefit from stabilization exercises to improve balance. 

Plan

It is recommended that Julie continue her exercises, increasing each one with an additional set of reps to solidify and consolidate her progress. She has also been provided with stabilization exercises to start with, and if this doesn’t improve, more exercises will be considered. She has also been prescribed more ibuprofen and panadol for any pain. 

Occupational Therapist

Physical Therapy

Physical therapy SOAP notes are a great way to document the nature of patient injuries, and how far along the patient is within their rehabilitation progress. This is excellent for noting target goals, as well as involving the patient in their treatment journey, as physical therapists can note down all the specifics and whether intervention is necessary. 

Subjective

Helen states that within the past week, the pain in her shoulder has been 4-5/10. She can now move her arm to approximately head-level without experiencing sharp pains. She has been using muscle relaxants to increase mobility and ease dull pain. 

Objective

The patient's PROM for flexion has improved from 80 degrees to 130 degrees. The strength in her range of motion has been enhanced from 3+/5 to 4+/5.

Assessment

The patient’s goal of full ROM into shoulder flexion has not yet been reached, however, the patient has made significant improvements concerning mobility, as Helen now reaches a larger range of motion. During the following three sessions, we will aim to continue to make improvements and work towards the goal of full ROM into shoulder flexion with the aid of exercises. 

Plan

Because Helen has made significant improvements with the current exercises, we will continue to implement them, and slowly increase flexor goals. Helen will be seen for a further three sessions at this stage. 

Physical Therapist

Mental Health

SOAP notes are an excellent tool for any healthcare professional in the mental health industry, which includes therapy, counseling, psychology, and psychiatry. They allow for mental health practitioners to record the patient experience concerning their mental health state, and allow for clear communication. Mental health professionals can gain valuable insights regarding the state of mind of patients, and can paint a representative picture of what the patient is struggling with. Considering mental health can evolve into much larger legal issues, it’s important that SOAP notes are kept for compliance reasons, to demonstrate clear clinical reasoning, and to abide by legal obligations. 

Subjective

Liam has difficulty breathing, stating, “I’m very hyper-aware of my breathing, and need to take extra effort in regulating my breaths. Sometimes it doesn’t work, and so I end up breathing shallower until I hyperventilate.” Liam says that this comes on unprovoked, which is amplified by anxious thoughts of when it will happen again. 

Objective

Liam has moderate anxiety symptoms, with the inability to control breathing and anxious thoughts. He presents a shaken appearance, with his heart rate confirming an above-average rate even while resting. Liam has no history of anxiety prior to the start of his symptoms one month ago. He has no family history. 

Assessment

Because Liam presents moderate anxiety currently, he needs treatment to find ways to combat his feelings, and to have effective techniques that work on controlling his breathing, and reducing his heightened state.

Plan

Liam will see me next week, and for a further three sessions to see if improvements take place. More sessions will be implemented if deemed necessary, and he has been provided with breathing exercises as a coping strategy to monitor and regulate his breathing. If symptoms worsen, this will be evaluated, and anxiety medication may be considered. 

Mental Health Therapist

Speech Therapy 

SOAP notes are a great way to assess progress when it comes to the language and speech abilities of the patient, and include information concerning their articulation, production of sounds, as well as their expression. It’s a great way to document patient progress, and ensure that the patient plays a role in their healthcare journey. 

Subjective

Sarah's mother said that "her teacher said Sarah is speaking slightly more often in class, and is slowly gaining more confidence. She volunteered to read aloud during a class reading time this week, which she doesn’t usually do."

Objective

Sarah demonstrates some expressive language, and some use of past tense (3/6), with a 50% accuracy. Sarah spoke about a fairy book she had read at home last week. Improvements will be needed so she understands tenses, as well as providing additional expression in her phrasing, voice, and lexicon choice. 

Assessment

Sarah improved somewhat, approximately 25%, in her use of past-tense language since the last session. She still presents difficulty with past-tense verbs, and pronouncing words, as well as placing the right expression and phrasing on certain sentences. Sarah has been diagnosed with a mild speech and language disorder. 

Plan

Sarah will continue with her treatment plan in increasing accuracy when it comes to past tense, and she has been supplied with exercises to promote more expression. She will continue sessions until she has shown marked improvements. 

Speech Therapist

Massage Therapy

SOAP notes are essential for massage therapists to incorporate into their practices, as they note the client’s progress in regards to their pain alleviation, and whether further treatment or interventions are needed. 

Subjective

John stated that he had a prominent pain in his neck and shoulders that hadn't gone away in the previous month. He rates his pain as a 4/10, and notes that it impairs his ability to lift heavier objects, and limits his mobility, especially when reaching in higher places. 

Objective

John received a full-body Swedish massage, and found that his ROM within the upper spinal area has some restriction. 

Assessment

John stated that following the massage, his pain had lessened, and he also responded well to the posture correction techniques and stretching exercises. No adverse reactions.

Plan

John has been given stretch exercises and posture techniques to work on alleviating his neck and shoulder pain, with his pain levels and posture being reassessed within his next session. Recommend sessions fortnightly for three sessions so he can have significant improvements concerning his pain. 

Massage Therapist

Acupuncture

Acupuncture SOAP notes are also valuable for practitioners to evaluate patient conditions, and can outline the specifics of patient information, such as the message herbal therapies used, as well as cupping, or heating pad application techniques. They should document everything the patient is experiencing, and how treatment works to alleviate health conditions and pain. 

Subjective

The patient demonstrated lower back pain within the past couple of weeks, with Henry stating, ‘it’s aggravated whenever I sit down.’

Objective

Henry demonstrated limited rotation in L5-L5, and reported pain within this area in the lower back. His left and right turns were within normal limits.

Assessment

With qi-deficiency and blood stagnation, the patient reports worsening of his symptoms since the injury. 

Plan

The plan is for Henry to return for the following three sessions at this stage, with more scheduled if there seems to be no apparent improvements. We will work to minimize his inflammation, as well reduce pain, and increase flexibility. 

Why is my profession not listed?

If you did not see your area of health listed here, don’t fret! While we explored some common healthcare professions that utilize SOAP notes, if you work under the health umbrella, then you can certainly implement them within your practice. They can greatly elevate the quality of your service, and are easily adaptable due to their flexible structure. It’s one of the most widely used formats, and so whatever healthcare specialty you practice, you can curate high-quality notes that incorporate the SOAP formatting and structure. 

HIPAA Compliance and SOAP Notes

HIPAA Compliance 

It’s important to make a note that healthcare compliance continues to have an essential role within SOAP notes, and you must be aware of the Health Insurance Portability and Accountability Act (HIPAA) guidelines, in order to remain legally compliant. 

The HIPAA standards outline that medical patient information must be protected at all costs, and within every business process of your practice. The guidelines ensure that your business operates smoothly, with patient information at minimal risk of hacking, and that you aren’t susceptible to data leakages. It outlines that medical and financial data must be kept private, and that every business is accountable for its actions. Failure to take action could result in expensive fines and penalties, with these violations having the potential to cause severe damage to the reputation of your practice. All transferring, sharing, and receiving of medical information must be secure and confidential. 

If you wish to share information, you must first obtain consent from patients, and have explicit authorization to do so. The only exception to this is if the patient is at risk, in which case, you may disclose information to the relevant individuals. Patients may also request access to their medical notes, which highlights the importance of only recording objective, professional, relevant, and factually-based information. 

HIPAA guidelines outline recommended security practices that you must implement in order to be legally compliant, and to ensure that your patient information is in safe hands. For example, you must have encrypted servers to store your SOAP notes, if using electronic recordkeeping, with a minimum of AES-256 encryption. You must also educate and train your staff on security protocol, and how to handle security breaches if the circumstance arises. 

Understanding all the rules and policies when it comes to HIPAA can be tricky, and we recognize that not every practice is able to continue with the evolution and continuous rule amendments. However, when it comes to SOAP notes, it is highly important that you are aware of the consequences that may occur if you fail to implement security protocol, and you must work to prioritize the security of your information. To delve into this further, feel free to check out our ‘Ultimate Guide to Healthcare Compliance’, otherwise, feel free to check out the links below. 

Benefits and Challenges to SOAP Notes

Advantages to SOAP notes

When it comes to SOAP notes, there are clear advantages to its use that can elevate the quality of care, as well as the continuity and coordination of it within your healthcare practice. Using the SOAP note structure allows you to prioritize the needs of your patients, whilst supporting concise communication for other healthcare practitioners to follow. 

Easy to understand: Because of the SOAP note format, which presents a highly professional and concise approach, it is very easy for healthcare practitioners to interpret and understand. Regardless of a clinician’s background or specialty, they can easily skim over SOAP notes and gather the important details and essential information with a clear summary. Only valuable and medically rich insights are recorded, meaning that the notes should be able to be understood across healthcare organizations. 

Ease of information sharing: Due to their easily digestible format, SOAP notes are quickly becoming widely accepted within the healthcare industry, and in many ways, they are considered a universal clinical note structure. As a result, if patients need to be referred across practices, healthcare professionals can quickly pick up on their cases. Thus, SOAP notes are an excellent way to share medical information without compromising the small details. 

Provides subjective and objective perspectives: SOAP notes are a great way to evaluate both subjective and objective observations, which is excellent in supporting a balanced assessment and analysis of a patient’s condition. Practitioners can understand the patient’s condition from their experience, based on their perception of symptoms and progress, as well as correlating this information with objective, observable facts. This way, patients can feel acknowledged in that their concerns are expressed and recorded, with medical practice also contributing to the overall outcome of treatment for the patient. 

Evidence of patient interaction: Each SOAP note contains information concerning the details, date, and time of each session, as well as any essential notes pertaining to the patient. This makes for excellent evidence that is highly relevant when situations may arise that require additional information to assert responsibility. It can make for great references in regards to past and future treatments, and simply listing the facts of patient interactions can work towards better record-keeping practices.

Elevates compliance: Not only are SOAP notes highly effective to implement within your clinic, but having progress notes is a legal requirement. In this case, particularly with vulnerable patients, there may need to be additional information included, and SOAP notes are an effective piece of medical evidence that covers all bases when it comes to the patient experience. For any regulatory, policy, or law issue, using SOAP notes can increase compliance, and ensure that you are abiding by sufficient healthcare compliance guidelines. SOAP notes provide and attribute accountability and responsibility to practices, to ensure that all practitioners are recording information that benefits the patient and actively works towards treatment that caters to their healthcare needs. 

Personal data collection: SOAP notes are also a great contributor to your collection of detailed patient notes, as it means you can keep your own database on medical issues. Many patients are likely to come to you with similar conditions, so it’s always good to keep concise notes that help you improve on past experience, and can be used to cross-reference and compare medical information. This contributes to a greater learning experience, and you can quickly understand what has worked and what hasn’t when it comes to patient health. SOAP notes are excellent reference points that allow you to improve accuracy and achieve higher clinical outcomes when it comes to your patients. 

SOAP note mistakes and how to overcome them 

SOAP note mistakes

To create the most effective SOAP notes, you need to ensure that you’re aware of common mistakes that are made, so you can avoid them and implement good practices right from the get-go. We acknowledge that SOAP notes can be quite meticulous in nature, and making these mistakes can result in misdiagnosis, ineffective treatments, and lower clinical outcomes, which isn’t desirable, and can lead to detrimental effects within patients if not handled appropriately and promptly. 

Making assumptions: You shouldn’t ever make general statements or assumptions that aren’t supported by evidence. Doing so can lead to false impressions and interpretations when it comes to patient health. The subjective experience is exclusive to the patient and their voice, with objective notes explaining, confirming, or negating what is expressed, which doesn’t require personal opinion and judgments. Within the plan section, general statements and assumptions can dismiss the patient experience, and prevent effective treatment that actually addresses true symptoms within the patient. 

Repeating information: Although some aspects of medical information link together, you still mustn’t repeat information. This can make for very lengthy SOAP notes, when they need to be concise so other healthcare professionals can easily pick up on the most important information to be able to treat patients. Repeating information also means that the majority of the notes are composed of irrelevant details, which can obscure valuable insight, meaning critical medical information may be missed. 

Rewriting: We all make mistakes, but if you need to rewrite information, you should make notes of amendments instead. This is much faster than rewriting the entirety of the SOAP note, which can take up a large chunk of time, and waste resources unnecessarily. If your amendments are clear and follow established business protocol, then you should be able to easily incorporate these within your original note. 

SOAP note mistakes

Unsourced quotes: As mentioned, you may need to include quotes from family members, or any other external party within your subjective statements. If you do so, you must make sure that you source the opinions and quotes so healthcare professionals can understand who exactly stated these. Family members and close contacts need to be documented, as this is far easier to attribute information and medical details in the case that the SOAP notes are referred to in the future. It proves that your assessment is based on factual information from your sessions, and that you haven’t falsified any details to suit a personal agenda, in which case, would result in costly repercussions. 

Incorrect timing: You must make sure that your SOAP notes are recorded, produced, and edited at appropriate times. Writing notes during the session is ideal for catching all essential information, but when doing so, you must ensure that you are still paying attention to every detail the patient states. Multi-tasking is difficult, so don’t be afraid to make pauses every now and then to catch up on information, as that way, you can ensure that no critical details are missed, and the patient feels heard. As well as writing too early, leaving things too late can also be a vital mistake. If you compose your SOAP notes at a later time, you may find that you have missed out on essential details simply due to forgetting, which could be detrimental. 

Poor correction method: Make sure that you have the right correction methods in place to appropriately and professionally correct any mistakes you make. Inevitably, you will make errors in your notes, and it’s important that you simply strike a line through the writing you wish to amend, and initial the mistake. This way, if other healthcare professionals review your content, they’re able to see the original content of the mistake, as well as who corrected it. This allows for greater responsibility and accountability to be attributed to each practitioner, and shows a linear correction process for all errors. 

Lazy treatment plans: A common mistake that many healthcare practitioners make when reaching the plan section, is to skim over with a generic plan that could apply to a variety of patients within their practice. You should be specific in a plan that addresses all symptoms the patient has brought up, and it should identify ways to combat and minimize their diagnosis pains. It should outline future steps, so there is no confusion regarding what the patient needs to do during the time between appointments and sessions. 

Tips for good SOAP notes

Now that you know the common mistakes and pitfalls of SOAP notes, it’s time to look at some practices you should implement to produce high-quality clinical notes that are sure to prioritize the needs of your patients and elevate the quality of your practice. 

Be neutral: Your clinical notes should be able to be read by fellow healthcare professionals, and they should not be able to tell who wrote it, and it should be detached from personal touches. Refrain from recording your personal assumptions, biases, judgments, and interpretations of information, especially within the subjective and objective sections. These should be based on the patient experience, as well as scientific facts. You should relay relevant medical information without distracting with your own opinion. Keep in mind that professional opinion may be used sparingly, and naturally, your expertise is used in the assessment and plan sections, however, this is still supported with medical evidence. Failing to stay neutral can diminish your professionality and authoritativeness, as well as create the potential for costly repercussions for your practice. 

Write professionally: Part of writing professionally means to have the correct spelling and grammatical structure within your notes, as well as avoiding slang, abbreviations, and colloquialisms. You should keep in mind that other healthcare practitioners will be reviewing and assessing your information, and so you must write with clarity and a high degree of accuracy. Doing so will highlight your medical reasoning, and will also mean your notes are overall easier to understand and interpret by others. Avoiding abbreviations is also good practice, as these can often be misconstrued, and so it’s best they’re avoided completely when it comes to SOAP notes. 

Quality over quantity: You must aim for conciseness within your clinical notes, as lengthy pages can take away from the important details, and it is far more beneficial to spend time making detailed observations with rich clinical reasoning. SOAP notes shouldn’t exceed more than 2 pages in length, and keeping them shorter, but with greater depth and analysis of information, is likely to prove more beneficial to the patient’s treatment. Considering that SOAP notes take some time to write, it’s important to spend your time productively.


Ensure legibility: Many healthcare professionals have different preferences when it comes to writing notes, and what works best for them. While the leading option, and most widely used one, is electronic notes, if you choose to handwrite the documents, you must ensure they are legible. Poor handwriting has infamously led to many misdiagnoses and missed information due to more effort needing to be spent on deciphering the content of the notes. If you prefer writing by hand, ensure that you have clear writing that can be understood by anyone who reads it, or consider taking up electronic SOAP notes. Typing is a skill that anyone can develop, and  it greatly reduces the risk of medical mistakes and errors, with the typed information being clear. Often, built-in software provides spelling and grammatical tools to help you write notes that are high-quality, without you having to worry!

Distinguish symptoms and signs: As mentioned, within the objective section, you should ensure you can wrap your head around the difference between both symptoms and signs. Symptoms are what is listed in the subjective section, and concern the patient experience of their pain. This is different from signs or symptoms that are included in the objective section. It’s important that these are not misconstrued, as they each have distinct purposes and provide value within their own rights. 

Perfect your timing: Make sure that you’re writing notes shortly after you’ve seen the patient, ideally within a specifically designated time that allows you to quickly note down critical details to avoid forgetting them. You can write your notes during your session, so long as you make pauses to ensure that you are attending to the information of your patient, and that you aren’t multitasking. 

Safely secure them: An important part of SOAP notes, as well as staying compliant with healthcare practices, is to safely secure the documents. Because they contain highly sensitive and personal information, failing to maintain privacy and confidentiality within these documents can result in costly repercussions and hits to your reputation. Abiding by HIPAA laws and regulations is critical to the success of your business, and when it comes to SOAP notes, these are no exception. If information is stored online, it must be within encrypted servers, with access restricted to only essential workers and staff that need the information. If notes are handwritten, these copies should be stored within advanced security systems, with top-of-the-line security systems and protocols in place.  

Conduct comparisons: It’s important that within the assessment section of your SOAP notes, you note the current treatment plan of the patient, and how effective it is for the patient. After all, a SOAP note is a progress note, and its purpose is to record how a patient is managing their current health, given the prescribed medical resources. You should make note of whether a particular treatment is taking the intended effect, and whether this needs to be changed. Comparison across sessions is strongly encouraged, and can be a good indicator for other healthcare professionals and providers who encounter patients with similar medical histories, or have the same referred to them. 

Final Thoughts

SOAP notes are an excellent form of clinical documentation, used by a variety of healthcare practices, and convey all essential details pertaining to patient health conditions. Because of their adaptable format and concise structure, SOAP notes are a great way to highlight critical medical information, and enable valuable insight to be generated for treatment improvements. Practitioners can produce higher clinical outcomes, with increased chances of medical reimbursement, and more streamlined communication. 

We recognize that it can feel daunting when looking at SOAP notes as a whole, and as a result, we hope our breakdown of the essentials is able to provide you with a greater understanding of what goes into high-quality clinical documents and notes. With SOAP note use, you can design the best treatments that deliver highly effective solutions to your patients, and work towards prioritizing their needs, and accomplishing healthcare goals. For further reading, feel free to check out the following resources:

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