How to Write SOAP Notes + SOAP Note Example and SOAP Note Templates

Oct 22, 2023 | 0 comments

Oct 22, 2023 | Blog | 0 comments

Crafting effective and comprehensive SOAP notes is vital for any therapist or clinician aiming to deliver optimal patient care. Documenting essential details from a therapy session, including the client’s appearance, presenting problems like shortness of breath, and the therapeutic approaches, facilitates improved communication and clinical reasoning. By incorporating key elements such as mental status and utilizing SOAP note examples and templates, clinicians can efficiently organize their observations and insights, ensuring a holistic approach to patient care and a clearer understanding of the client’s progress.

Table of Contents

What is a SOAP Note

A SOAP note is a communication document that contains information about a patient that can be passed on to other healthcare professionals. The name is an acronym for Subjective, Objective, Assessment, and Plan. Our SOAP note example and SOAP note template below can be used as a guide for recording clinical observations and summarizing care plans, clinical information, and nursing diagnoses.

SOAP Note Acronym

S-Subjective

The note’s subjective section (S section) includes different information the patient has shared about his symptoms and feelings about his condition. This section may also include information from family members and friends of the patient. The S section may also include specific information about the medical history of every person, relevant client behaviors, and social circumstances.

Example. Client reported _____________ problem, feeling, action, etc.

O-Objective

Objective data includes vital signs and test results that healthcare professionals have recorded.

A SOAP note’s objective sections (O section) include the observable or measurable data. It is important to remember that the information in this section is strictly objective and factual, meaning that it does not include the practitioner’s interpretation or opinion. Instead, the data collected here comes from tests or examinations performed by healthcare professionals. For example, if a patient complains of chest pain and has an elevated heart rate and blood pressure, this information would be included in the O section.

The Objective section is NOT the place for opinions, connections, interpretations, etc.

The O section might begin with an introductory sentence outlining the session’s length.

Example. Client participated in ____minute session in _______setting for skilled instruction/intervention in _____________.

Sometimes, the O section then gives an overview statement summarizing observations and client deficits. This is optional.

Example. Client presents with ___________ (disease, disability, deficit, etc.).

Next is the most important part of the O section—what happened and what you observed. There are multiple ways to organize an O section.

Chronologically
This might be the easiest way to organize it, especially if you are new to SOAP notes.
Chronological order means you write what happened in the order it happened.
Ex. First, the client…..Second, the client…….Next, the client…..
If you organize it chronologically, include all treatments and relevant observations, but remember that you do not have to include every detail of what happened.
Categorically
Categorical means organizing the O section according to categories of things you and the client did or observed.
Example. Category/Deficit #1
Example 1
Example 2
Category #2
Example 3
Example 4
If you organize it categorically, sometimes it is helpful to group things into broad categories because there may be overlap between one section and another.
Evaluation Findings
If the session was an evaluation, the SOAP note may look a little different
An evaluation SOAP note must include all scores from the eval. This could include:
Summary of Screening results
Assessment/Test/Evaluation results
Pictures
Observations during evaluation
Evaluation scores can be listed in bullet points or paragraph form.
Ex. Name of Assessment
Category: Result
Observations
Sometimes, it makes sense to incorporate observations throughout, but some people find it helpful to create a section in their O-section for observations.

A-Assessment

The assessment section of the note contains a diagnosis based on the data gathered in the previous sections. It may also contain progress notes regarding the prognosis of the patient’s condition.

This section is also where the provider lists possible diagnoses or problems based on subjective and objective data. The assessment section may also include a statement of what is causing the problem or condition (etiology), the risk factors for developing this condition, and its implications for future health.

In the A section, you make sense of what you wrote in the O and S sections.

Many A section includes 3 P’s plus needs:

Problem or Cause-Effect statements
These statements interpret and explain the patient’s problems, evaluation findings, and observations.
A statement of progress (progress notes)
Sometimes, we can compare the scores or observations from our O section to what we have seen in the past week.
This is important because someone reading your SOAP note now understands whether your O section shows the patient is making progress or not.
A statement of potential
While focusing on the problems and issues is easy, we also want to highlight things in the previous section that indicate this client’s potential.
This could include the client’s strengths, support system, attitude, etc.
A summary statement of needs
This is often a justification for services or a justification for discharge.

Example:

Problems: ______________(condition/deficit) causes client difficulty with ________________ (occupation).

Potential: Client shows rehab potential to make progress as indicated by ______________ (supports/client factors/ etc.).

Progress: Client demonstrated progress in _________ (during session or throughout therapy).

Justification of services: Client would benefit from skilled intervention/instruction focused on __________________________ (tasks/strategies for specific occupations).

P-Plan

The plan section outlines any further testing or treatment needed for the patient’s condition.

This is where the provider states what will be done to manage the condition or problem identified in the assessment section. The plan may include specific treatments, medications, referrals to other providers for further testing or treatment, instructions for home care, etc.

The P section includes any treatment recommendations or referrals to specialists or other care providers required by the patient’s condition or symptoms. This section might also include relevant lifestyle changes to be considered by the client.

Example:

Continue tx ___min #x/wk for # wks to work on ____________ (intervention) for _____ (goal/occupations).

Referral to___________ recommended to address_______________.

Family provided with resources including _______________________.

Purpose of SOAP Notes

The soap note’s proper purpose is to facilitate patient care. It contains the client’s medical record and the patient’s health status.
The soap note provides a place to track medical issues in one location, with all members of the healthcare team. or when services of others are needed, tracking issues becomes easier.
It also helps to facilitate communication by providing an easy way for healthcare providers (HCPs) to quickly get a picture of what is going on with the patient. Use language common to all health practitioners.
The soap note also allows HCPs to more easily share information about a patient when referring them to specialists or when multiple HCPs are involved in their care.
It can be used as evidence in case law, but it should always be written to focus only on objective findings and evidence-based treatment plans. The subjective portion of the note should focus on what you see, hear, feel, and smell while at the bedside.

SOAP notes Abbreviations

Some commonly used abbreviations for SOAP notes are:

b/c- because

CC- chief complaint

c/o- complained of

cl- client

d/t- due to

Dx- diagnostic test

Ed- education

e.g., exempli gratia, use when giving an example

HPI- history of present illness

i.e., id est, use when giving alternative explanation or wording

min, mod, max- minimum, moderate, maximum

Mx- monitoring test

Rx- treatments

sx- symptoms

w/, w/o- with, without

How to write SOAP Notes

Taking thorough and accurate SOAP notes is crucial for any counselor or therapist. It helps record a client’s progress and serves as a useful reference point for the future. Here’s a simple guide to writing SOAP notes:

Subjective Observation: Start by jotting down how the client appeared during the session. Did they seem distressed, calm, or withdrawn? Encourage using direct quotes to capture the client’s exact words, providing valuable insight into their emotional state. For instance, if a client with major depressive disorder expressed feelings of persistent low mood or social isolation, noting these verbatim quotes can offer a nuanced understanding of their experiences.
Objective Findings: Record specific observations and measurable data. This can include the results of any assessments conducted during the session. For example, if you’re a speech therapist, you might note the patient’s speech and language development within normal limits or any changes observed over time. These objective findings provide a solid foundation for clinicians to effectively address the patient’s illnesses.
Assessment: Provide a brief evaluation of the client’s progress and any changes in their condition or behavior. This is where you can delve into your clinical analysis, discussing the client’s insight and judgment based on their responses during therapy. For instance, if a client has been working on addressing social isolation, you can assess the effectiveness of the strategies implemented and the client’s evolving perspective.
Plan: Outline the next steps or action plan for future sessions. This could involve adjustments to the therapeutic approach, additional assessments, or referrals to other specialists. Documenting this plan in the SOAP format ensures a clear roadmap for the client’s continued progress. Remember, detailed therapy notes can guide future sessions and contribute to the overall effectiveness of the treatment.

Tools for writing SOAP notes

There are several helpful tools available that can make the task of writing SOAP notes more efficient and organized. Here are some of the key tools to consider:

Electronic Health Record (EHR) Systems: These digital platforms have become a cornerstone in modern healthcare facilities. EHRs allow healthcare professionals to easily input and access patient information, including SOAP notes, test results, medications, and other vital data. They often come equipped with templates and forms to create structured SOAP notes.
SOAP Note Templates: These pre-designed forms provide a structured framework for organizing patient information. They typically include dedicated sections for the subjective, objective, assessment, and plan components of the SOAP note. Templates can help ensure that all the necessary information is captured systematically and organized.
Voice Recognition Software: This technology enables healthcare providers to dictate their SOAP notes using voice commands, which are then transcribed into text by the software. It can significantly expedite the process of note-taking and documentation, allowing practitioners to focus more on patient care. Popular voice recognition software includes Dragon Medical and Nuance.
Pen Tablets or Digital Pens: These devices allow practitioners to write directly onto a digital surface, easily converted into digital text. This tool is particularly useful for those who prefer the tactile experience of writing by hand but still want the convenience of digital documentation. Digital pens like Livescribe and Wacom are widely used for this purpose.
Mobile Apps for Note-Taking: Various mobile applications are available that facilitate the creation of SOAP notes directly on smartphones or tablets. These apps often come with features such as customizable templates, voice recording options, and integration with EHR systems, making them a convenient option for busy healthcare professionals on the go. Examples include Evernote, Notability, and OneNote.
Medical Dictionaries and Resources: Access to reliable medical dictionaries and resources can aid healthcare providers in accurately documenting medical terms and conditions. These resources can help ensure that the terminology used in SOAP notes is precise and standardized, contributing to effective communication among healthcare professionals.
Progress Note Templates: Utilize readily available progress note templates specifically designed for your field of practice, whether speech therapy, behavioral therapy, or any other specialized area. These templates serve as a structured framework, guiding you to include essential information systematically.
Practice Management Software: Invest in reliable practice management software that simplifies creating SOAP notes. Look for user-friendly software for easy data customization and integration, ensuring a seamless experience documenting client progress and treatment plans.
Physical Examination Tools: In cases where physical health plays a role in therapy, having basic physical examination tools on hand can be invaluable. These tools can help you collect objective information about the client’s overall health, providing a comprehensive perspective on their well-being.
Consider Social Factors: Acknowledge the significance of social factors in the client’s therapeutic journey. Incorporate assessment tools that enable you to understand and document the influence of social support and other external factors on the client’s progress and well-being.

5 top software solutions to write SOAP notes

Here are five user-friendly software solutions that are specifically designed to facilitate efficient and organized SOAP note-writing:

SimplePractice: Known for its user-friendly interface and customizable features, SimplePractice is a popular choice among therapists. It allows for seamless integration of SOAP notes into daily workflow, enabling clinicians to create detailed and well-structured documentation effortlessly.
TheraNest: TheraNest is another reliable software solution that offers a range of tools to streamline SOAP note writing. With its intuitive design and various customizable templates, TheraNest helps therapists efficiently organize client information and track progress over time.
Kareo: Kareo is a comprehensive practice management software with SOAP note functionality. Its user-friendly interface and robust features make it an ideal choice for therapists to streamline their documentation process and ensure accurate record-keeping.
TherapyNotes: TherapyNotes is a widely trusted software solution that caters specifically to the needs of mental health professionals. Its intuitive interface and comprehensive features make it a valuable asset for therapists seeking a reliable platform for creating SOAP notes and managing client information.
CounSol.com: CounSol.com is known for its simplicity and ease of use. It offers a variety of customizable templates and features that allow therapists to efficiently create SOAP notes and maintain detailed records of client progress and treatment plans.

Why use software for writing SOAP notes?

Efficiency and Time-Saving: Software streamlines the process of documenting SOAP notes, saving valuable time for therapists and allowing them to focus more on patient care rather than paperwork.
Improved Organization: Software provides a structured platform for organizing and storing SOAP notes, ensuring easy access to patient information whenever needed.
Customizable Templates: Many software solutions offer templates tailored to specific therapeutic practices, facilitating consistent and comprehensive documentation.
Data Security and Privacy: Reliable software ensures the security and privacy of patient data, adhering to strict regulations and protecting sensitive information from unauthorized access.
Integration with Practice Management: Some software solutions seamlessly integrate SOAP note writing with practice management tasks, enabling therapists to streamline various aspects of their practice, from scheduling to billing.
Enhanced Collaboration: Software allows for easier collaboration among multidisciplinary teams, fostering better communication and coordination in the delivery of patient care.
Accurate and Detailed Reporting: Software generates accurate and detailed reports based on the data entered, providing valuable insights for treatment planning and decision-making.
Remote Access: Many software solutions offer the flexibility of remote access, allowing therapists to create SOAP notes from any location with an internet connection, enhancing convenience and accessibility.