Noting down the client progress is a very important component of treatment. It is also critical to the health of the treatment. Therefore, it is important to document all patient encounters and one of the common and effective ways of doing that is Writing SOAP notes to accompany all sessions.
What is SOAP in full?
SOAP is an acronym for Subjective, Objective, Objective, Assessment and Plan
What is a SOAP note?
A SOAP note which is an acronym for Subjective, Objective, Objective, Assessment and Plan is a documentation used by healthcare professionals to write patient notes in form of charts and other formats
What are the 4 parts of a SOAP note?
Explain the 4 parts of a Soap note
S (Subjective): This section of a SOAP note describes the client impressions and supports them with observed facts. They include descriptions of client feelings, performance and interactions.
O (Objective): This part of a SOAP note documents the measurable outcomes about the client performance, including the test scores, percentage of goals achieved and quantitative information.
A (Assessment): This part of a SOAP note describes the doctor’s analysis, interpretation and the client progress. It also documents the strengths and areas that require improvement, and compare performance to previous sessions.
P (Plan): This section of a SOAP note outlines the next steps in the treatment process. It states all the activities, objectives and reinforcements that may need to be changed in case the client continuous to get low scores
4 Mistakes to be Avoided When Writing SOAP Notes
- Including statements in a SOAP note without supporting facts. For instance, stating “client was willing to participate” is a mistake because it does not provide facts to support observations.
- Including general statements in a SOAP note without supporting data. Excessive supporting data to describe activities that clients participate in must be included.
- Rewriting what has already been stated in the objective and subjective sections of a SOAP note in the assessment section. This is the section that requires the client progression and regression discussed and factors that attribute to changes assessed.
- Rewriting the entire treatment plan. This is where specific information on the next steps to achieve the treatment goals should be addressed.
Tips for Writing Perfect SOAP Notes
SOAP notes are very important in the treatment process. To come up with an effective SOAP note, the following tips must be followed
- Considering the timing aspect: for full attention purposes, SOAP notes should not be written after each session; they should be kept in the private psychotherapy notes before they are entered into the EHR after each session
- Being concise: a SOAP note should be easy to read to quickly communicate information to other physicians, overly wordy statements should be avoided
- Being specific: SOAP notes should not only be concise but also specific. This is achieved by the use of precise details that help prevent confusion and improve treatment.
- Avoiding judgmental statements: professionalism should be maintained in SOAP notes; they should remain as neutral as possible. That implies avoiding excessive negative or positive wording and focusing on accurate information.
- Avoid naming others: the names of family members, clients or anyone named by the patient should not be included in a SOAP note. Instead, initials should be used to denote the people mentioned by the client.
SOAP Note Examples
SOAP note Example 1: Psychiatry SOAP note
Subjective: Mr. A. states that he has “generally been doing well.” His depressive symptoms have improved, but he still feels “down” at times. Mr. A. says he is sleeping “better” and getting “decent sleep.” He feels his medication is helping him without causing side effects.
Objective: Mr. A. appears alert. His mood has improved, and he shows a range of emotions.
Assessment: Mr. A. has major depressive disorder without psychotic features.
Plan: Mr. A. will continue taking 10 milligrams of fluoxetine per day. If his symptoms do not improve in one week, we will consider increasing the dose to 20 mg. Mr. A. will continue outpatient counseling.
SOAP note Example 2: Individual Therapy
Subjective: Mr. G states he has strong cravings for heroin, and he thinks about leaving his treatment program to get drugs “several times a day.” Mr. G wants to stay sober and says he’s “better, but still not strong enough.” Mr. G states, “I can’t stop thinking about using, and I can’t seem to get it out of my head.” The client says he’s “improving overall.”Objective: Mr. G appears calm and interested during the session. He does not display any signs of withdrawal, such as sweating or tremors. Mr. G is still distractible, but his attention has improved, as indicated by talking about his wife for five minutes and reflecting on his past without difficulty.Assessment: Overall, Mr. G is improving. He is learning to apply coping skills such as relaxation techniques, and he is more engaged in his treatment. His cravings have decreased from “all the time” to “about six times a day.” However, Mr. G continues to experience strong cravings and has a 30-year history of substance use. Therefore, he needs to learn new coping skills to manage his emotions. Considering the challenges Mr. G faces, he may be a candidate for medication-assisted treatment (MAT).Plan: Mr. G has now received information about MAT to discuss during the next session. We will begin to use cognitive behavioral therapy techniques to address Mr. G’s anger issues. We will also continue to hold family sessions with his wife. Staff will continue to monitor the client closely.Looking for Academic Writing help
Looking for Professional Soap Note Writers Make an Order Now