SOAP notes are a form of clinical documentation used globally across various healthcare practices. They aim to convey essential details from a session with a client, including symptoms, diagnoses, treatment, and progress.
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SOAP notes are a form of clinical documentation that is used across various healthcare practices. They aim to convey essential details from a session with a client, including symptoms, diagnoses, treatment, and progress. SOAP notes allow practitioners to identify successful aspects of their treatment and improve communication with clients.
Importantly, progress notes are also legal documents that can be reviewed by other healthcare providers, insurers, and lawyers, so maintaining good clinical documentation is in the best interest of all healthcare practitioners. Using a secure digital platform to store your documentation helps streamline this process and ensures that all of your clinical notes are in one safe place.
SOAP notes are structured into four separate sections; subjective, objective, assessment, and plan. Using this format will guarantee you include all necessary information and that your clinical documentation is consistent across clients.
Writing adequate documentation can be assisted by using a SOAP notes platform. Often, these include helpful templates and guides and ensure your documentation is securely encrypted and stored to protect client privacy.
Writing adequate clinical documentation, while time-consuming, will ensure your protection and provide clients with the best quality of healthcare possible. Although the general structure of a SOAP note is the same across different healthcare fields, the specific information included will depend on the services that you offer. Below is a compilation of the types of information that should be included in SOAP notes for counselors, occupational therapists, physical therapists, speech therapists, and massage therapists.
Counseling SOAP notes should include the patient’s chief concern and their symptoms related to this concern. The counselor should report their observations about the patient’s behavior and affect and provide examples of these. Any progress noted in the patient should be included and recommended changes or modifications to the treatment plan. Below is an example of a subjective section from a counselor SOAP note:
An occupational therapy SOAP note should discuss any differences noted in the patient’s disability and illness and whether the treatment program has made a notable impact. The activities that were completed during the session, such as playing card games, practicing getting dressed, or engaging in a motor skills game, should be included and the patient’s performance. The SOAP note should conclude with relevant goals for the patient and the date and time of their next session. Below is an example of an objective section of an occupational therapy SOAP note:
Physical therapists should explain the client’s presenting problem, and a diagnosis or any difference noted since the previous session. Information regarding how the condition impacts the patient’s daily life, the level of their pain, and results from assessments and tests should also be included. Below is an example of an assessment section of a physical therapy SOAP note:
Speech therapy SOAP notes should identify the specific speech or language problem that was addressed during the session and the activities that targeted this. The therapist should indicate whether the patient has displayed improvement since the previous session based on in-session assessments, as well as the patient’s (or caregiver’s) subjective opinions. The SOAP note should conclude with an outline of the patient’s treatment plan to have measurable and achievable goals to work towards. Below is an example of a plan section from a speech therapy SOAP note:
A massage therapy SOAP note should outline the patient’s chief concern and why they require massage therapy. Details of the duration and frequency of the top concern should also be included and a rating of pain based on a scale. The therapist should identify what type of massage their patient received and whether the treatment changed their symptoms. It is helpful to complete a pain rating following treatment to indicate whether the message was successful. Below is an example of a subjective section from a massage therapy SOAP note:
SOAP notes are an important feature of operating a successful healthcare business. Using a SOAP format can streamline your clinical documentation and ensure all practitioners are maintaining clear and consistent notes. Efficiently writing SOAP notes can be further assisted by using a digital healthcare platform. These platforms can help healthcare businesses with appointment scheduling, medical billing, encrypting clinical notes and E.H.R., and providing patients with a portal so they can connect digitally with their practitioners.
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