What is a Psychology SOAP Notes Template?
A SOAP note is a specific type of formatting structure that helps psychologists organize their progress notes. Following each session with a client, psychologists are required to write progress notes that detail relevant information regarding that session. SOAP notes separate this information into four sections:
Subjective: The subjective section includes the patient’s description of their concern. This section often includes direct quotes from the patient and information regarding symptoms and how the concern is impacting their everyday life.
Objective: The objective section refers to your clinical observations about the patient’s behavior, response to intervention, and any tests or examinations that were completed.
Assessment: A synthesis of the previous two sections, the assessment is your professional interpretation of the session. This includes any improvements or declines in health you have observed, how the treatment plan is progressing, and whether the patient has achieved their goals.
Plan: In the final section of the SOAP note, the plan outlines the details of upcoming sessions, any changes to the treatment plan, and goals that the patient has.
Using a SOAP note format as a psychologist will help you keep your documentation clear, concise, and organized. As the most popular format for progress notes, the SOAP structure is also very useful for communicating between different members of a patient’s care team.
How to Use This SOAP Note Template for Psychology
This SOAP note resource has been designed to simplify the clinical documentation process at your psychology practice, so accessing and using it is very easy. There are a few steps you should follow to ensure you are getting the most out of the resource:
Step One: Access the PDF resource
The first thing you need to do is access the PDF SOAP note template. We’ve included a link on this page, and you just need to click through to it and you can start editing and filling out the relevant sections.
Step Two: Fill in the four SOAP sections
After you have accessed the PDF, you will be able to fill in each of the four sections. It’s important to remember that staying on top of your documentation will help improve productivity and ensure you don’t have a pile of notes to write on Friday afternoons! After each session with a client, you should access the SOAP note template and write your documentation.
Step Three: Don’t forget your credentials
In addition to information regarding the session with the patient, you also need to include specific credentials. These include the patient’s name and ID, the date and time of the session, and your own professional credentials.
Step Four: Store the SOAP note securely
After you have written your SOAP note, you need to store it securely. Because SOAP notes contain confidential information, it is absolutely essential that you have physical and/or electronic safeguards in place to protect your patient’s privacy.
Psychology SOAP Note Example (sample)
To help you visualize what the psychology SOAP note will look like once completed, we’ve created a sample note. This should indicate the type of information that fits within each section so you can feel more confident using our template.
Who Can Use This Psychology Template?
We know that there is a range of different psychologists who specialize in various fields. This is why we’ve made sure our SOAP template is able to be used by a wide variety of different psychologists, including the following:
- Clinical Psychologists
- Clinical Neuropsychology
- Educational Psychologists
- Developmental Psychologists
- Counseling Psychologists
The SOAP note can also be used by psychologists who specialize in different types of patients, including:
Finally, a psychologist may be treating a group of patients together (for example, a family). You can use our SOAP note template to record information from these sessions, but we do recommend creating a separate note for each patient. This ensures that all of the relevant information is included, and you don’t accidentally forget any important details.
Why is This Template Useful For Psychologists?
Utilizing this SOAP note template has a range of different uses for psychologists, including the following:
- Organization: Staying organized as a psychologist is very important. In addition to all of the clinical work requirements, there is a range of different administrative tasks that you also need to complete. By using our SOAP note template, you can ensure that the work you complete is highly organized and follows an intuitive system.
- Timeliness: Writing your progress notes in a timely manner will help boost your productivity. We understand that psychologists lead very busy lives and that sometimes timeliness is difficult to achieve, which is where our SOAP note template comes in. By using a document that is already separated into four relevant sections, all you have to do is fill in the details, making clinical note-taking easier than ever.
- Consistency: Because SOAP notes are often shared between different members of a patient’s care team, it is important that you try and keep them as consistent as possible. Our SOAP note template guarantees this type of consistency, allowing other third parties to access important information easily.
Benefits of Using the Psychology SOAP note template
There is a range of different advantages that are associated with using a SOAP note template as a psychologist. These include:
Facilitating improved communication between the different members of a patient’s care team should always be a top priority. With our SOAP note template and the consistency it guarantees, effective communication is made much easier. Providers can access important information regarding a patient’s health and they can consequently make better and more informed clinical decisions.
The most important aim of SOAP notes is to track the progress of patients. By using a template, you are guaranteed to produce highly accurate notes, which in turn will allow you to track the progress of your patients.
Psychologists lead busy lives and are always on the lookout for ways they can streamline their tasks. If this is the case for you, then using a SOAP note template might just be the perfect solution. The template will be readily available and you don’t have to spend any time creating a structure or organizing a format - all that work has already been done for you!
If a patient’s insurance provider is paying for their sessions, then the provider may request to view the relevant SOAP notes. Using our SOAP note template will help make their job easier, as they can quickly scan the document and locate the important information.
Progress notes are legal documents. If a situation were to occur that involved you or your clinical decisions, you will need to produce your SOAP notes. Using a template increases the likelihood of having accurate SOAP notes which in turn will be extremely useful should a legal situation ever arise.
Under the law, patients always have the right to access their own SOAP notes. For this reason, it is very important that your documents are organized, accurate and truthful; and using a template can help ensure this is the case.
Why Use Carepatron for Psychology SOAP note?
Practice management systems offer a wide range of tools that assist in the production of effective SOAP notes. Carepatron is an all-in-one platform that is guaranteed to streamline your clinical note-taking process, saving you countless hours that can instead be spent completing more pressing tasks. In addition to offering SOAP note templates, Carepatron’s software is integrated with voice-to-text transcription, as well as has high-end storage capabilities. An entirely HIPAA-compliant platform, Carepatron ensures that you and your patient’s data is protected at all times, with both physical and electronic safeguards in place.
Carepatron doesn’t just offer clinical documentation resources; the platform is also integrated with medical billing, coding, appointment scheduling, patient engagement, and communication features so your psychology can optimize its workflow and continuously elevate productivity. Finding ways to save time within a psychology practice should always be a top priority and Carepatron offers a fantastic solution for this - while also improving the quality of the work you are doing.