For therapists, psychologists, psychiatrists, and other medical professionals, documenting client interactions and their progress are a critical part of treatment. Documenting every encounter is also very important to the health of your private practice. One of the most common and effective techniques to document a session is called writing SOAP notes. In this post, we will review what SOAP notes are, how to write a SOAP note, tips for effective SOAP notes, and a template you can use for your SOAP notes.
What are SOAP Notes?
So what are SOAP notes? According to the U.S. National Library of Medicine, “The Subjective, Objective, Assessment and Plan (SOAP) note is an acronym representing a widely used method of documentation for healthcare providers. The SOAP note is a way for healthcare workers to document in a structured and organized way.”
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Why are SOAP Notes Important for Private Practice?
Creating effective SOAP Notes are invaluable to running a thriving private practice. We asked Dr. Carolina Raeburn about why that is:
“Soap notes make the most clinically relevant information easy to find. SOAP notes help a private practice by providing organization, clarity, and a framework for clinical reasoning”
How to Write a SOAP Note
In this section, we are going to outline each section of a SOAP note and what to include under each section. Let’s break down each section of SOAP:
“Subjective” is the first heading of a SOAP note. This section contains the “subjective” experiences, personal views, or feelings of the patient or someone close to them.
Chief Complaint (CC)
The chief complaint, or the problem being presented by the patient, can be a symptom, condition, previous diagnosis, or another statement about what the patient is experiencing currently.
The chief complaint will give the reader of your SOAP note a good sense about what the document entails. Some examples of a Chief Complaint for someone in the mental health field include: Feelings of prolonged unhappiness.
A patient may have more than one Chief Complaint. Their first complaint may not be the most significant one. It’s important to get your patient to state all of their problems so that you can determine which problem is the most significant. Finding the main problem is important to perform effective and efficient diagnosis of your patient.
History of Present Illness (HPI)
The history of present illness is a simple, 1 line opening statement that includes your patient’s age, sex and reason for the visit
Here is an example: 16 year old female experiencing prolonged unhappiness
The HPI section is where your patient can elaborate on their chief complaint. This section should include:
- Onset: When did your patient’s Chief Complaint start?
- Location: Where is your patient’s Chief Complaint located?
- Duration: How long has your patient’s Chief Complaint been going on for?
- Characterization: How does your patient describe their Chief Complaint?
- Alleviating and Aggravating factors: What situations or factors make your patient’s Chief Complaint better or worse?
- Radiation: Does your patient’s Chief Complaint stay in the same area or does it move to new areas?
- Temporal factor: Is the CC worse (or better) at a certain time of the day?
- Severity: Using a scale of 1 to 10, 1 being the least, 10 being the worst, how does the patient rate the CC?
You should review different aspects of your patients history including but not limited to:
- Medical history
- Surgical history
- Family history
- Social history
Review of Systems (ROS)
Reviewing of systems is a system-based approach that helps you uncover any symptoms not mentioned by your patient previously.
Current Medications, Allergies
In this section, you should include the medication name, dose, route, and how often your patient takes medications, if applicable.
What to Avoid in the Subjective Section
Don’t include general statements in the Objective section without facts that supports your statement.
The next section of SOAP is the Objective. This includes items that are objective (hence the name!), such as:
Your patient’s vital signs
Findings from your patient’s physical examination
Data from lab tests
Results from xrays and other imaging
Other diagnostic data
Review of documentation from other clinicians
What to Avoid in the Objective Section
Don’t include general statements in the Objective section without data that supports your statement.
The assessment section of SOAP takes into consideration both the Subjective and Objection sections to create a diagnosis of your patient. This section includes a few subsections including:
In this subsection of Assessment, list out the problems your patient has in order of importance. A problem is often known as a diagnosis.
In this subsection, you will create a list of different possible diagnosis. At the top of this list should be the most likely diagnosis, followed by less likely in order. In this subsection, your decision-making process should be outlined in detail. You should also include a possibility of other diagnosis and how each could affect your patient.
What to Avoid in the Assessment Section
Don’t rewrite what you have written in your Subjective and Objective sections.
The final section of SOAP is the Planning section. this section addresses the need for additional testing and potential consultation with other clinicians to address any of your patient’s illnesses.
This section should also address any additional steps you’re taking to treat your patient. The Planning section helps future professionals to understand what needs to be done next.
For each problem, you should include:
- Testing needed and why you chose this test
- Medication needed
- Specialist referrals required
- Education or counseling for your patient
What to Avoid in the Plan Section
You should avoid rewriting your entire treatment plan. This is the section that should specify next steps in reaching your patient’s goals.
Advantages of SOAP Notes
SOAP notes are great because they create a uniform system of your patient’s information. Without SOAP notes or other similar organized methods, every document would be different and difficult to quickly glance through for medical professionals. Here are some advantages of SOAP notes:
- SOAP notes are uniform system of tracking your patient’s information
- SOAP notes help other medical professionals thoroughly understand your patient’s issues
- SOAP notes help organize the most accurate information so that treatment can be the best possible
- SOAP notes adopt medical terms that most everyone in the medical field understands
Disadvantages of SOAP Notes
While the advantages of SOAP notes are many, here are a few disadvantages:
- Some practitioners note the excessive amount of acronyms and abbreviations used in SOAP notes
Tips for Effective Soap Notes
SOAP notes are only a tool to help practitioners. We are going to highlight tips for effective SOAP notes.
Write SOAP notes at the appropriate times
Avoid writing SOAP notes when you’re seeing your patient. You should be taking personal notes to help you write your SOAP notes later. Also, try not to wait too long to create your SOAP notes.
Maintain a Professional Voice
You should use a professional voice throughout your SOAP notes. Avoid informal language.
Be Specific and To the Point
You should avoid vague descriptions or wordy descriptions.
Avoid Overly Positive or Overly Negative Phrasing
You should not interject overly positive or negative slants in your SOAP notes.
Don’t Be Overly Subjective Without Evidence
You should avoid using blanket statements or statements that aren’t backed up by evidence.
Be Accurate and Non Judgmental
Your SOAP notes should be professional in tone and non judgmental. A good way to think about this is to imagine writing your SOAP notes for your patient’s family member to read. Will it offend them?
Conclusion on SOAP Notes
We hope this post has been helpful to you on how to write a SOAP note. SOAP notes are an incredible tool you can use to properly keep track of patients and provide them with the best possible treatment. SOAP notes are also incredible valuable for keeping your private practice healthy.
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