Private Practice
May 19, 2021

What Is A SOAP Note & How To Write Them (+ Examples)

Are you looking for a better way to manage your progress notes?

SOAP notes can be a powerful tool for simplifying your clinical practice. They provide a quick way to capture, store and interpret your client's information consistently, over time. Spending too long capturing progress notes can be a colossal waste of time and money for your healthcare business.

Without a framework in place, it can be challenging to manage your clinical notes effectively, leading to a reduction in the standard of your client's health records and practice management overall. A SOAP note template helps you to capture the information required consistently while also enabling your team to quickly get across the information they need when they need it.

So let's start with the basics.

This Article Contains:

  1. What is the purpose of a SOAP note?
  2. What is SOAP Note format?
  3. How do you write a SOAP note?
  4. Why SOAP Notes Are an Important Tool
  5. SOAP Note Examples
  6. Free SOAP Note Templates
  7. Tips for Writing SOAP Notes
  8. Common Mistakes to Avoid
  9. Final thoughts

What is the purpose of a SOAP note?

SOAP notes are a clinical method used by healthcare professionals to simplify and organize a patient's information. Healthcare practitioners use the SOAP note format to record information in a consistent and structured way. 

The SOAP note format helps health practitioners use their clinical reasoning to assess, diagnose, and treat patients utilizing the information presented. SOAP notes are a critical information source for the patient's health status and a communication tool for different health professionals. The SOAP note template structure acts as a checklist, enabling practitioners to capture the information consistently while also providing an index to retrieve historical information if required.

The SOAP note structure was first theorized by American Physician Lawrence Weed more than 50 years ago. He wanted to provide clinicians with a template for specific tasks while providing a framework for evaluating information. Today, SOAP notes are considered the US Healthcare standard for capturing clinical information across healthcare professions.

Organising a SOAP note template

What is SOAP Note format?

SOAP is an acronym that stands for subjective, objective, assessment, and plan. The elements of a SOAP note are:

Subjective (S): Focused on the client's information regarding their experience and perceptions of symptoms, needs, and progress toward treatment goals.

Objective (O): Includes observable, 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): Includes the clinician's assessment of the available subjective and objective information. The assessment summarizes the client's status and progress toward treatment plan goals.

Plan (P): Records the actions to be taken due to the clinician's assessment of the member's current status, such as assessments, follow‐up activities, referrals, and changes in the treatment. 

How do you write a SOAP note?

What are the four parts of a SOAP note? What should be included in a SOAP note assessment? 

Let's examine each section in detail, discussing what you need to have while sharing specific SOAP note examples.

Subjective – The "history" section

The first step is to record the patient's chief complaint or to present the problem, to capture all the information they share about their symptoms. This section requires you to discuss 'their experience with the patient' condition, focusing on their needs and treatment goals.

The Subjective summary includes direct quotes from the patient. For example, they might say, "I want to take a holiday to focus on my mental health." The Psychologist would capture this quote verbatim. It's important within this section to record the patient's exact words so that you can connect these insights to your last recommendations, and other members of your team can understand the specific detail of your conversation.

The Subjective section also allows you to document any comments made by the patient's family members or their care team. 

It is common during this step for practitioners new to this method to list their impressions successfully but fail to qualify these with observed facts such as symptoms or questions/comments from the patient.

You must take the time required to document the highest-quality information possible as subjective provides the basis for your later clinical reasoning. 

OLD CHARTS acronym is a handy method for clinicians to ensure they are capturing all of the necessary information.

  1. Onset: When each symptom started.
  2. Location: Find out the primary area of pain or discomfort.
  3. Duration: Learn how long the patient has experienced these symptoms.
  4. Characterization: Examine the types of pain — swelling, aching.
  5. Aggravating or Alleviating factors: What actions or interactions increase or reduce the patient's symptoms?
  6. Radiation: Confirm if the pain radiates to other parts of the client's body.
  7. Temporal pattern: Do the symptoms present in a pattern, like in the mornings or after exercise?
  8. Severity: On a scale of one to ten, how does the patient rate the severity of their symptoms?

Other things healthcare workers can include in the subjective section are:

  1. Past medical history
  2. Symptoms
  3. Social and family history
  4. Present illnesses

Subjective content example

Sarah states: "I didn't go to work today because I felt depressed all yesterday." We discussed the importance of work to regulate her moods and ensure she does not become avoidant when experiencing depression.

Sarah reports frequent depressive episodes and low moods during the past week & says, "I just wake up feeling low for no reason. I don't know why". During my previous interaction with Sarah, we described problems getting to sleep, often waking up during the night. We discussed how vital sleep is to regulate her emotions and depression.

Common Subjective mistakes 

Statements without supporting evidence: Capturing statements like "clients were unable to describe their wellbeing" is an opinion until you support this observation with verified facts or quotes. 

Including irrelevant information: Clinicians need to focus on their notes' quality and clarity rather than include excessive detail.

Paraphrasing clients: It's essential to capture the exact quote your client says. I know this can be tricky to practice as your writing notes while speaking with your client. Just take the time you need. It's worth it!

Objective – The physical exam and laboratory data section

The objective is to include factual information and measurable outcomes such as tests, assessments, and percentages of any goals tracked. Often contains detailed observations about the client's presentation, behavior, language, and mood. For example, you may document that the client arrived 1 hour early to the session and sat in the reception tapping on the table.

This section would typically contain precise data or quantifiable outcomes. Write details down as factually and precisely as possible. Documenting the Objective phase can be demanding as you are required to separate symptoms from signs. Symptoms are the patient's experience of their condition; signs are objective observations of symptoms. If a client reports having anxiety symptoms, such as social panic attacks, signs of that anxiety may include dry mouth, clenched muscles, body shakes, and hypertension.

You have limited time for examination, so it's crucial to actively look for any signs that complement or contradict this information in the Subjective section.

Data or observations to include:

  1. Temperature
  2. Weight
  3. Blood pressure 
  4. Heart rate
  5. Physical, interpersonal, and psychological observations
  6. General appearance
  7. Mental status
  8. Client's capacity to participate in the session
  9. Client's responses to the process
  10. Psychological tests or assessments
  11. Any medical records from other healthcare providers can be included here (if applicable)

Examples: 

  1. Sarah is agitated: aware of her surroundings but quickly distracted. Her communication is slow, and at times off-topic. 
  2. Sarah participated during today's session positively and openly.
  3. Sarah's appearance is unkempt, with potential low hygiene. Below her typical standard.

Common mistakes to avoid

  1. Ensure you don't make any general statements or impressions without any supporting data.
  2. Avoid personal judgments or opinionated statements.
  3. Communicate precisely. 
  4. Use professional language without any negative connotations and are open to individual interpretations (ex: looks homeless, seems like an average person, drunk).

Assessment

The assessment enables a practitioner to describe and comment on their overall evaluation of a client's condition. This section also acts as a wrap-up of the appointment or interaction, with providers typically commenting on the patient's overall progress.

This section documents the synthesis of "subjective" and "objective" evidence to define a diagnosis. This section assesses the patient's overall progress through a systematic analysis of the problem, possible interaction, and status changes. 

For frequent conditions such as depression or anxiety, the assessment may be straightforward and can often lead to clear progress or diagnosis in a short time. For more complex health issues or conditions, such as co-morbidly, you will typically require more time or interactions to gather the information needed to make a diagnosis.

The assessment covers evaluating the client's progress toward agreed treatment goals or objectives for follow-up sessions. This section will inform your treatment plan; this can depend on how the client is engaging or responding to treatment. Documenting the progress or improvements your client is making is essential. 

Information to include in the assessment section are:

  1. Diagnoses 
  2. Patient progress
  3. Changes in medication or treatment

Mistakes to avoid:

  1. Avoid repeating your statements from previous sections. This section should only include progress, regression, or changes to the treatment plan.
  2. Like the other SOAP notes sections, your assessment should only contain relevant information written professionally.  

Plan

Of course, as the name implies, where the previous three sections all come together to help you determine the best course of treatment for your client. This is where the health practitioner records any changes to the patient's treatment plan. This section often includes changes in activities, goals, and medication. 

Things to include in the plan section are:

  1. The treatment provided during the session and your rationale for administering it
  2. The client's immediate response to the treatment
  3. When the patient's next session or interaction will be
  4. Any homework or information you gave the client
  5. Goals and outcome measures for additional or re-assessed problems.

Your plan documentation should include actionable items for each diagnosis. If your client is experiencing other problems simultaneously, you should separate a separate plan for each condition.

The purpose of this section is to address all the specific deficits listed in the assessment. When done efficiently, the plan sets a concise roadmap for the patient's continuing treatment and provides insight for other clinicians to progress treatment if required.

Examples of things to include in the plan:

  1. Introduce designated assessments to assess the client's condition.
  2. Focus on the client's reported daily functioning issues, including frequency, duration, intensity, and type (if applicable).
  3. Build trust and confidence with the client to enable a productive relationship. 
  4. "Client will engage with a Psychologist to explore CBT group sessions."
  5. "Client will begin exercising four times per week at a local gym."
  6. "Client is hesitant to reestablish group sessions for substance abuse."

SOAP Note Examples

Psychiatrist

Subjective

Ms. M. states that she has "been doing ok." Her depressive symptoms have improved slightly; however, she still often feels "low." Ms. M. says she is sleeping "well" and getting "7 hours sleep per night" She expresses concern with my note-taking, causing her to be anxious during the session. She also expressed concern with occasional shortness of breath. 

Objective

Ms. M. is alert. Her mood is stable, improved, and she can regulate her emotions.

Assessment

Ms. M. has a major depressive disorder with a family and social history.

Plan

Ms. M. will continue taking 20 milligrams of sertraline once 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.

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.

Psychologist

Subjective Complaint

"I'm tired of being overlooked for promotions. I don't know how to make them see what I can do."

Objective Findings

Frasier is sitting in a chair, slumped forward, and burying her face in her hands. Frasier completed Release of Information, allowing consultation with a primary care physician. 

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

Consider assertive communication and problem-solving skills.

Therapist

Subjective section

David states that he continues to experience cravings for methamphetamine, and he has considered dropping out of his treatment program to buy drugs "every single day." David is motivated to stay sober and says he's "sober, but still not enjoying it" David states, "I dream about drugs all the time, and I can't seem to quench my thirst," The client says he's "fit and strong overall."

Objective observations

David is present and engaged during the session. He does not display any signs of being under the influence or withdrawals. David remains aroused and distractible, but his concentration has improved. This was indicated by discussing his partner for fifteen minutes and his ability to reflect on his history.

Assessment

Overall, David is making progress. He applies skills such as control techniques, exercises and he is progressing in his treatment. His cravings have decreased from "every moment" to "every hour." However, David continues to experience regular cravings with a 10-year history of methamphetamine use. David needs to learn additional coping skills to manage his emotions. Considering the difficulty David faces, he may benefit from DBT treatment.

Plan

David has received psychoeducation within his therapy session. The therapist will begin to use dialectical behavioral therapy techniques to address David's emotion dysregulation.  He will also continue to hold family therapy sessions with his wife. Staff will continue to monitor David regularly.

Free SOAP notes templates

There are many free SOAP note templates available for download. These templates are typically in word or PDF format, so you can easily make changes to them.

School of Medicine template: UMN offers a simple SOAP notes template for medical specialties, including psychiatry, asthma, psoriasis, pediatric, and orthopedic. This template is available in PDF format and word format.

SampleTemplates: This platform offers SOAP notes templates related to nursing, physical therapy, pediatric, clinical therapy, and more. The formats for downloading the templates are word DOC and PDF, and the file size starts from 4KB.

Templatelab: This website offers free SOAP notes templates for a range of healthcare professions, including mental health, speech therapy, school counseling, psychology, and more. The templates are available as DOCX and PDF files, and their size starts from 2KB.

Tips for Writing SOAP Notes

Here are our top tips on maximizing the value of SOAP notes regardless of your profession or clinical discipline.

SOAP note software: Capturing and storing your SOAP notes in the cloud is the single best way to ensure consistency and access to the information required. If cost is an issue, here is a fantastic platform we recommend.

Use a great template: If you don't have practice management software, you can follow a simple SOAP note template (Word or PDF). This will help you manage and organize the information your team is capturing. Following a consistent template will help you ensure that you consistently capture the patient's most critical information.

Length: SOAP notes should be 1-2 pages long for each session. Typically most sections are 1-2 paragraphs in all (up to 3 when necessary).This gives a complete overview of the session, the patient's progress, and treatment plan without the information becoming too long or complex for healthcare professionals to consume quickly. 

Consistency: Using a SOAP note template will help you and your team maintain consistency of the format, length, and abbreviations. It will also support your team to quickly consume notes as they will be familiar with the flow. 

Storage: The information you record during this process is often sensitive and includes health information governed by HIPAA compliance. Ensure you are taking the necessary precautions to keep this information safe and in an environment where you can control it.

Purpose: Whenever you're documenting a SOAP note, the note's purpose should always be front in mind. Frequently, healthcare professionals write so many notes in the role that it feels like a low-value operational process. This method aims to inform other practitioners about the patient's current status and progress. They are also used to document the need for these sessions to an insurance company to reimburse you.

Write your notes like your client is reading them: We all know clients can request a copy of their notes. If you keep this in the back of your mind as you're writing them, it will help you keep them concise and professional.

Complete progress notes for every session: To capture full documentation for your patient's problems, you should create a note for every appointment. If you start skipping sessions, it will dramatically reduce the method's value over time.

Focus on the patient's problem: At its core, SOAP notes are designed to help you manage and organize your treatment plan.

When you create goals, utilize the SMART goals framework. SMART goals are easier for caregivers and other involved parties to digest and support.

A SMART goal is:

  1. Specific
  2. Measurable
  3. Attainable
  4. Relevant, and
  5. Time-Based.

Focus on consistency across your team: Changing the way you and your teamwork can be difficult sometimes. We all know how powerful our existing work habits can be. Focus on a whole team approach. There is limited value to SOAP notes when only some of your team are following the method, sometimes. You need to ensure once the framework is in place, it's followed every time.

Timing is everything: Aim to implement the SOAP note framework during a time of the year when your team is most likely to have the capacity to adopt it. Allow practitioners time to work through the format slowly for the first few days.

SOAP note tips

Common Mistakes to Avoid

Here are a few common mistakes to avoid when writing SOAP notes.

Repeating yourself: In the Assessment section, do not rewrite what you stated in the Subjective or Objective sections.

Writing too many notes in the session: Give your client all of your attention; avoid writing SOAP notes within your sessions. We recommend capturing some brief notes as you go focusing on quotes. Write your SOAP notes in your Electronic Health Record (EHL)  platform following each appointment; avoid waiting too long, so the specifics are fresh in your mind.

Judgmental statements: Ensure you use professional language in your notes and be as neutral and balanced as possible. Avoid overly positive or negative wording and focusing on giving accurate information.

Naming family members: Avoid including the names of family members, other clients (particularly in group therapy), or anyone else named by your patient. Instead, you might use initials or a numeric to indicate the person your client is referencing. By stating your client's name, you clarify to other healthcare professionals that your client is the complete focus of the documentation. It also protects the privacy and security of others.

Avoid acronyms and abbreviations: It's best to minimize acronyms and abbreviations to prevent misinterpretation. If you must use abbreviations, develop and implement an agreed list with your team.

Making assumptions: Avoid using language like "appeared" or "seemed" as these demonstrate suppositions and lead to confusion. Instead, only include facts and observations which focus on only what the client physically does or says aloud.

Common SOAP note mistakes

Final thoughts

Whether you're an Nurse, Allied health practitioner, therapist, mental health worker, or medical professional, you'll spend less time creating better documentation with SOAP Notes. The best place to start is with free SOAP note software or with a SOAP note template. High-quality SOAP notes can help your team reduce complexity, save time and provide better health outcomes for their clients.

To get started, why not sign up for Carepatron today and take advantage of its feature-rich FREE plan. You'll be able to turn your team from a group of loveable (but uncoordinated) professionals to a high-performing team, just like that!

SOAP Notes conclusion

 

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