What is a Therapy SOAP Notes Template?
Therapy SOAP notes are one of the most common clinical documentation formats, as they capture rich clinical information, and contribute to more informed treatment plans. Following a SOAP note therapy example ensures that you get it right every time, and integrating our embedded template guarantees higher accuracy in regard to your client.
Therapy SOAP notes cover four important sections, which include the following:
This section focuses on the unique experience of the client and aims to address their symptoms and concerns through their perspective. Expect to include direct quotes, secondhand commentary from close relations, and annotations of their current physical state.
Using data that can be measured, the objective section covers all observable facts. This may entail vital signs, such as blood pressure, height, and weight, as well as other assessments, medical records, and x-ray evidence. It is scientifically based, with all statements requiring supporting evidence.
Synthesizing both the subjective and objective information, the assessment section requires an overall clinical assessment. This should summarize the current health of the client, and typically involves notes on any current medications, treatments, and how they are progressing in regard to each aspect.
In the final section, you will need to develop a plan to define and carry out the next course of action for your client. This may mean amending current treatment plans or recommending a new one entirely.
How to Use This SOAP Note Template for Therapy
Using SOAP note templates for your therapy practice can significantly boost the quality of your clinic, however, you may be wondering, how exactly do you use them? Fortunately, using SOAP notes is a super easy, intuitive tool that enables you to work smarter, and improve the formatting of your notetaking.
Step One: Download the PDF template
Before you go any further, make sure that you have the template downloaded on your chosen note-taking device. Your PDF software should also allow you to make edits to the page.
Step Two: Fill out your credentials
At the top of the page, you will need to fill out the date and time of your session with the client, as well as their name and ID, and your own professional details.
Step Three: Complete the four SOAP sections
Fill out the four subjective, objective, assessment, and plan sections, making sure that you cover all bases. It’s important to have all evidence in one place, and that all information is succinct and concise. Keep in mind that other practitioners may need to evaluate your notes, especially in case of legal action, so you should maintain a professional tone, with only factual data included.
Step Four: Sign
For verification, legal, and insurance purposes, it is recommended that you sign the document at the bottom of the page. It recognizes authority and ownership and ensures you are accountable for the expertise you provide.
Step Five: Store your SOAP notes
After saving your SOAP note, it is very important that you store the document within a HIPAA-compliant platform. This significantly reduces the risk of security breaches, and ensures that your information is safeguarded and protected.
Therapy SOAP Note Example (sample)
Using our therapy SOAP note example, you can ensure you tick all boxes, and maintain a high level of consistency across all the SOAP notes you create. Not only does this save time, but it also leads to much higher clinical outcomes for you and your patients – which is always a win!
Who Can Use this Therapy Template?
SOAP notes use a medically universal format, which makes for great applicability across a variety of disciplines. Regardless of the type of therapy field that you work in, almost all mental health practitioners can benefit from integrating this template within their workspace. Therapists can capture a more accurate diagnosis, and communicate client conditions in rich detail without compromising on quality.
There are many types of therapy that use the SOAP format. Therapists that can benefit from implementing SOAP notes in their practice include the following:
- Cognitive Behavioral Therapists
- Dialectical Behavioral Therapists
- Addiction Therapists
- Child Therapists
- Clinical Therapists
- Exercise Therapists
- Trauma Therapists
- Nutritional Therapists
Although every therapist will conduct their business differently, and the content within the SOAP notes may be unique to the field, the format remains the same across all areas. The four subjective, objective, assessment, and plan areas will be covered in extensive detail, which is relevant for all types of therapy. Each SOAP note should also pertain to one individual only, which is a key note to remember if you are more inclined to conduct group sessions.
Why is This Template Useful for Therapists?
SOAP notes have a variety of different uses, and they can enhance your note-taking skills and accuracy within your practice. There are a multitude of reasons why you should incorporate SOAP, including the following:
- Universal design: SOAP notes are super useful for therapists in that they utilize a universal design that makes for easy accessibility. Other members of your care team, as well as other healthcare professionals, can view your notes and easily pick up where you left off.
- Higher convenience: SOAP notes cover all essential bases, meaning the hard yards has already been done for you. Once you’ve filled in the required sections, you’re done!
- Greater insurability: Quite often, you may need to present your clinical documents in legal cases, or for insurance claims. SOAP notes are designed with this intention, and ensure that you comply and are safeguarded when it comes to third-party assessments.
Benefits of Using the Therapy SOAP note template
Beyond necessity, there are several reasons why incorporating SOAP notes within your practice can actually elevate the quality of your clinic, broaden your clientele, and increase your revenue.
SOAP notes are a heavily streamlined tool, meaning that they cover all essential bases, and you can get straight to the point. Integrating their formatting significantly saves time, and allows you to do what you do best. As you know, therapists can lead intensely busy schedules, so it’s important that you use your time wisely.
Higher clinical outcomes
With SOAP notes, you can effectively track client health progress, and record more accurate information that touches on multiple subjective and objective realms. As a result, you can improve communication, and the clinical decisions you make with a more accurate representation of the client’s condition.
It’s important to standardize your notes, as not only does it facilitate professionalism in your work, but it also ensures that they are as consistent as possible. SOAP notes are a great way to implement this, as it means you can carry the same quality and criterion across your clients.
At the end of the day, SOAP notes are used to organize a variety of information pertaining to the client’s condition. It combines assessment results as well as medication and treatment plans all in one place. With SOAP, you don’t have to peruse through multiple files to find what you’re looking for.
SOAP notes are a great way to collect secondhand assessments from the client’s close relations if needed, which provides wider scope to the picture of their health. It’s a unique approach, that enables healthcare practitioners to draft progress notes and treatment plans with the direct needs of the client in mind.
Why Use Carepatron for Therapy SOAP note?
Used by over 10,000+ healthcare professionals, Carepatron is the leading option when it comes to creating, storing, and managing SOAP notes. Designed with therapy needs in mind, Carepatron allows you to incorporate templates for the most high-quality documents. From a rich resource library, you can choose and adapt templates to whatever best suits your needs. Manage your workflow, and streamline your operations with an intuitive system that increases both efficiency and productivity.
Additionally, Carepatron utilizes voice-to-text transcription software, so you don’t need to lift a finger. All you have to do is speak into the microphone, and Carepatron picks up on every word you say, noting it within the SOAP template. Once completed, you can then store your notes within a top-notch security system, that offers bank-level encryption and round-the-clock monitoring. It’s the best way to stay HIPAA compliant, whilst offering your clients the best treatment possible.