Simple and effective SOAP notes

Writing SOAP notes is an integral aspect of most healthcare professions, but it's unlikely to be why you work in your field. Make taking your notes fast and efficient with excellent software and resources.
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Simple and effective SOAP notes

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The worlds best SOAP Notes

The worlds best SOAP Notes

While writing SOAP notes is an integral aspect of most healthcare professions, it is unlikely they are why you chose to work in your field. The importance of SOAP notes should not be underestimated; they can help organize your work in a professional sense and can be used in situations with other healthcare providers, legal workers, and insurance companies. SOAP notes are an effective formatting structure for your clinical documentation regardless of what specific field you work in, and we have developed a detailed guide to help you write your notes as efficiently and concisely as possible.

SOAP notes you and your clients will love

SOAP notes are structured into four distinct sections, each relating to a different session element: subjective, objective, assessment, and plan. An external healthcare provider with no previous involvement with a patient should extract the necessary information from a SOAP note and appropriately treat them.

Here are some of the key features that should be included in an ideal SOAP note:
1. Personal details of the patient, including name, age, and relevant medical history. 
2. The reason why the patient has made an appointment (this is often referred to as the chief complaint/CC). Details regarding when symptoms began and how much they impact the patient’s everyday life are also included.
3. Vital signs and measurements of the patient, including blood pressure, weight, and height.
4. Any physical examinations, tests, or measurements that were completed during the session and the results.
5. A diagnosis of the chief complaint is based on the above information provided.If the patient has been seen previously, then the note should include professional commentary on the progress of the symptoms and complaints.
6. Details of a treatment plan devised for the patient, including medication, exercises, referrals, and future medical appointments.

Although this seems like a significant amount of information, in reality, a SOAP note shouldn’t take a physician more than 10 minutes to write. Complicated sessions that involve numerous tests and examinations will generate more detailed SOAP notes, but conciseness and clarity should always be a primary consideration when writing your notes.
SOAP notes you and your clients will love

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How To Write Great SOAP notes?
What Are SOAP Notes?
SOAP notes are the most effective way to write progress notes for your patients, enabling you to professionally organize your work in a way that can be understood by healthcare professionals across a variety of disciplines. Not only are they essential for legal compliance, but SOAP notes are also an excellent medical documentation formatting structure that covers four aspects that are integral to the success of patient treatment.
Read guide
How To Write Great SOAP notes?
How To Write Great SOAP notes?
SOAP notes are the most effective way to communicate and document a patient’s symptoms, diagnosis, treatment plans, and other important details concerning their health. They are a widely recognized note format that are easily understood by most healthcare practitioners and can be tailored to specific needs of your healthcare practice, regardless of your health discipline.
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Understanding a SOAP Note format

Subjective (S)The subjective section should begin with a statement regarding the patient’s relevant symptoms and complaints. The location, severity, and duration of the symptoms.How the patient’s symptoms are impacting their day-to-day life. Direct quotes from the patient or their parents/caregivers effectively describe the patient’s subjective experiences. 

Objective (O)Quantifiable and measurable data was gathered during the session, including diagnosis, physical symptoms, and affect. Professional opinion regarding how the patient presented themselves during the session, based on eye contact, attentiveness, perceived nervousness. When writing about this information, it is essential not to be assumptive. All of your claims should be accompanied by evidence, e.g., “Jane actively participated during the session, promptly replying to questions and initiating a conversation.” The patient’s vital signs and measurements, height, weight, and blood pressure.Findings of clinical examinations.The results of tests completed during the session, including blood tests, x-rays, or CT scans. 

Assessment (A)
A professional evaluation of the patient and their symptoms, based on the documented subjective and objective information. Based on professional opinion and clinical criteria, with references to diagnosis models (DSM). Comment on the general progress of the patient since their previous session and whether they are displaying any improvement. 
  
Plan (P)
The future course of action regarding the patient’s treatment. Achievable goals for the patient to work towards between sessions. Future sessions, referrals to other healthcare providers, medications, and further examinations if relevant.
Understanding a SOAP Note format

Key To Write Great SOAP notes

Maintaining good clinical documentation is a central aspect of providing patients with quality healthcare. To help you in your process of efficiently producing high-quality SOAP notes, we have collated a list of critical considerations to keep in mind when writing your clinical documentation.

Quality Over Quantity: Conciseness is one of the essential features of a good SOAP note. While they should include all relevant information, your SOAP note should never exceed two pages in length. Avoid using vague language or repetitive sentences, and make sure that everything you include is relevant and informative. 

Get Them Done: Physicians typically lead hectic lives filled with appointments, meetings, and administrative tasks. As such, it is easy to see how clinical documentation can be procrastinated. However, writing a SOAP note immediately after a session will ensure you haven’t forgotten any details that may be important: accuracy is critical! SOAP notes also shouldn’t take you more than ten minutes to write, so staying on top of them will be a more productive use of your time in the long run. 

Maintain Professionalism: The subjective section of a SOAP note primarily refers to the opinions of the patient, not the physician. Although the physician needs to comment on their judgment of the patient’s symptoms, these judgments need to be backed up by factual evidence and not based on personal assumptions. Avoid words that have negative connotations, e.g., obnoxious or rude.

Legibility: It might seem obvious, but the importance of having legible SOAP notes is often overlooked. If you choose to keep handwritten clinical notes, your handwriting should be neat and easy to understand. On the other hand, you might find it easier to guarantee legibility by writing your letters electronically. Specific healthcare platforms also offer SOAP note templates that can improve consistency and streamline your clinical documentation process.

Storage: The information included in a SOAP note is often private. While SOAP notes can be shared between other healthcare providers and insurance companies, they must be stored securely.
Key To Write Great SOAP notes
Common SOAP note examples and templates

Common SOAP note examples and templates

While the specific information included in clinical notes will largely depend on your healthcare professional and the services you offer, the SOAP note structure can be effectively utilized by many different healthcare physicians. 

Speech Therapy 
Excerpt from a subjection (S) section of a speech therapy SOAP note: 
Ben’s mother said that Ben is “initiating conversation more frequently at home and his teacher said he has been putting his hand up in class to answer questions more than he ever has before.” 

Counseling
Excerpt from an objective (O) section of a counseling SOAP note: 
Sarah completed a Kessler-10 depression scale with a score of 25, indicating some presence of depressive symptoms. Sarah appears tired and disinterested, offering short responses to questions. Her sleep tracker suggests she has been sleeping an average of six hours every night.

Mental Health
Excerpt from an assessment (A) section of a mental health SOAP note: 
Josh has made some improvements since the previous session. He reports sleeping an average of six hours uninterrupted sleep each night, which is a two-hour improvement from the last session. He is taking his medication regularly and reached his goal of completing thirty minutes of exercise three times a week. 

Occupational Therapy
Excerpt from a plan (P) section of an occupational therapy SOAP note:
Angela should continue the current treatment plan, with one additional rep added to her knee exercises each week. The next session is scheduled for one week from today.

Massage Therapy Excerpt from a subjective (S) section of a massage therapy SOAP note: 
The patient has a dull aching pain in his lower back that worsens with rotational movement. Symptoms have been present for six weeks. The patient has been seeking massage treatment weekly for the past four weeks. The current pain rating is 3/10.

Trusted by healthcare professionals

Carepatron’s clinical note software has helped healthcare professionals worldwide stay on top of their note-taking and deliver high-quality care to their patients. But don’t just take our word for it!

Clinical Psychologist
“We utilize the customizable clinical note templates to quickly and consistently write notes. Some of our team have also fallen in love with the speech-to-text tool; this medical transcription helps those who are a bit slow at typing to be more productive.”
Sohrab N
Clinical Psychologist
Therapist
“What I like about Carepatron is that I can use the healthcare template library, which provides me with best practice resources at the tips of my fingers whenever I need them. I often attach healthcare consents and client intake forms to my notes for easy reference and forward my messages to other clinicians, clients, or teams.”
Jacky P.
Therapist
Physical Therapist
“Previously, my work was quite disorganized, with handwritten notes, ‘post-its,’ and files all over the place. Having access to a user-friendly clinical note product like Carepatron allowed me to introduce some much-needed efficiency and organization into all the chaos of my day.”
Nico B.
Physical Therapist
Healthcare Practice Owner
“Better than the best clinical document tool! It’s been a real ‘wow’ experience for our healthcare practice. It has saved our healthcare team time and provides a simple way of uploading medical documentation and updating client health records.”
Min W.
Healthcare Practice Owner

SOAP Note Blogs

Given the necessity and popularity of using a SOAP format when writing clinical documentation, Carepatron has created various healthcare professions, including counseling, mental health, occupational therapy, massage therapy, psychology, and psychiatry. We have included links to blog pages that contain strategies for different healthcare professionals to write practical clinical notes.