SOAP Progress Notes Template
A SOAP progress note template that helps to improve your clinical notes while saving you time.
Fact Checked by Ericka Pingol.
What is a SOAP Progress Note Template?
SOAP notes are a notetaking format used broadly within the healthcare workspace, and they benefit healthcare practitioners by structuring notes through a highly effective approach. Regardless of whether your field is in nursing, psychology, dentistry, occupational therapy, or otherwise, if you reside in a healthcare space, you can certainly take advantage of the benefits SOAP progress notes have to offer.
SOAP covers the four following sections:
Subjective
This section pertains to the client’s experience of their health concerns. This requires an outline of their feelings, thoughts, and commentaries on current treatment or medication. Using direct quotes, the subjective section is exclusive to the patient’s perspective.
Objective
The objective section is then used to support evidence from the previous section. Using observable information, you should cover details such as medical history, and any relevant examinations and test results.
Assessment
Combining evidence from subjective and objective observations, it is important that this section summarizes your professional judgment. This should involve commentary on the current state of your patient, and what potential directions you could move towards.
Plan
Finally, this section drafts a specific course of action for your patient, and how you will address the concerns discussed within the session.
SOAP Progress Notes Template
Check out this SOAP progress note template to elevate the quality of your clinical notes. Check out the free resources below:
How to Use this SOAP Progress Notes Template PDF
SOAP progress notes are super easy and intuitive to use - but if you’re unsure how to approach them, follow these steps. You can easily implement them within your practice, and make sure that you’re integrating them correctly.
Step One: Access and download the template
If you’re using the template we’ve provided, make sure to click the link to download it. Open the PDF in your default PDF reader to edit (or click to print if handwriting is your preference) and you’re on your way!
Step Two: Fill out your credentials
The next step is to enter all the important information that can help identify your client, and represent their health condition holistically. This means that you need to fill out the SOAP note with the date of your session with the client, in addition to their name, and ID (if there is one).
Step Three: Write the 4 SOAP sections
At the heart of SOAP notes lie its 4 components, the subjective, objective, assessment, and plan sections. To complete the SOAP note, you should enter information in each of the parts, with only critical information listed concisely. It’s okay if some sections are longer than others
Step Four: Sign and date the note
At the bottom of the SOAP note, include your signature and today’s date for authorization purposes.
Step Five: Securely store your SOAP notes
Once you’ve finished the entire SOAP note, make sure that you securely store it, ideally within a practice management software platform. This can help you stay HIPAA compliant, and provides a greater barrier of protection against data breaches.
SOAP Progress Notes Example (Sample)
To help guide you, and make sure you’re on the right track to success, we’ve created an example of a SOAP note, as well as a template for you to follow. Healthcare can be complicated, and we acknowledge that not everyone has the experience of working with SOAP notes, which is why we’ve made things easy. Simply download the link, and access the template in seconds,
To download the basic structure of a SOAP progress note, click here:
Who Can Use this Progress Notes Soap Template?
The great thing about SOAP progress notes is that they’re applicable to healthcare professionals across a variety of fields. Because the format is universal, almost any practitioner and clinician within a health specialty can adapt the note template to accommodate their needs. It’s highly flexible, with each of the 4 SOAP sections highlighting important components for high-level evaluation of patient health conditions. Individuals that can utilize this SOAP progress note template include:
- Nurses
- Doctors
- Psychologists
- Counselors
- Therapists
- Physical therapists
- Occupational therapists
- Acupuncturists
- Dentists
- Social workers
No matter your specific discipline, you can benefit from incorporating SOAP notes into your practice for easy organization, and a simplified workflow. You can consistently create notes that represent the patient's condition with a high level of accuracy, and that prioritize their needs first. Although each healthcare professional will approach SOAP notes differently, and the content within the SOAP sections will be unique to the field they specialize in, the general formatting stays the same. You can note all critical information without having to extensively plan, and create notes that are accepted by all professions.
Why Is This Template Useful For Healthcare Practitioners
SOAP progress note templates are immensely useful for healthcare practitioners, as they touch on the following points:
- High patient monitoring - SOAP note templates are a great way to monitor and track patient progress in regard to their health. The notes are made after every session with a client, meaning that you have specific points of reference for future direction.
- Efficient organization - With the SOAP note outline, you can record all subjective and objective observations in one place, so you don’t miss a thing.
- Evidence-based approach - SOAP notes compile a range of evidence, meaning that you formulate effective assessments and action plans that address specifics of your patient’s situation.
Why Use Carepatron For SOAP notes?
Used by over 10,000 healthcare professionals, Carepatron is an excellent choice for managing, creating, and storing your SOAP notes. With an extensive resource and template library, created by healthcare professionals, you can access the right support to effectively evaluate your patients. Incorporate templates that cover all the essential details, and produce valuable insight to elevate clinical outcomes within your practice.
Not only this, but with Carepatron, you can store all your clinical documents and access them from one place. With round-the-clock monitoring and 24/7 support, you can store documents in a HIPAA-compliant manner. You can protect all your information, as well as from legal and insurance cases that may arise. Have peace of mind when it comes to developing patient plans, and elevating the quality of your healthcare services. Boost your care, and ensure that you’re continually prioritizing the health of your patients without compromising on quality.
Commonly asked questions
While there’s no standard word limit for each section, it’s important that you cover all relevant information while being concise. As a good rule of thumb, try not to exceed more than 2 pages in length for your whole SOAP note.
It is advised that you do not use abbreviations in your SOAP notes. While shorthand can be more convenient, it is also more difficult for others to understand. Especially as various abbreviations are used across a variety of healthcare professions, and they all can represent different concepts even if given the same letters.
Yes, you can include images, so long as they represent the client’s health condition. This means including images of test results, x-rays, and any other relevant evidence.
