Keeping client notes is not only an essential part of practice methodology; it's a legal requirement for any competent and compliant practitioner. Often keeping a paper trail of every client interaction can feel a bit overwhelming sometimes.
SOAP notes are a widely used progress note format that enables practitioners worldwide to record their notes consistently. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. It guides a practitioner through the details required to produce a comprehensive progress note.
Subjective refers to the client's perception of their symptoms, needs, and progress towards treatment goals. Meaning the details reported back to the practitioner via the client. Noting down comments made by the client verbatim and inserting them into this section is an excellent habit to get into for the subjective section of the SOAP note.
Objective refers to the practitioner's observations regarding the client's screening tools, historical information, medications prescribed, and vital signs. These are details noted by the practitioner and give a broader picture of the client's physical and mental status.
Assessment is a summary of both the subjective and objective sections of the note. It is a beneficial tool for clinicians if they require a pre-appointment reminder of the last session. This section will note the perceived progress towards the treatment goals and essential details from the previous two sections.
Plan refers to the agreed course of action decided between the practitioner and client. It will include specific and measurable goals considered in the follow-up for the client. The plan may consist of further assessment, activities, referrals, and changes in treatment, and any follow-up appointments that may be required.
No matter what part of the healthcare sector you practice within, SOAP notes are beneficial to keeping good client notes. You'll spend less time creating documentation and feeling confident you haven't missed any critical sections of the note.