Using the SOAP template when note-taking enables practitioners of all specialities to communicate in a streamlined fashion.
A SOAP note is a progress note that contains specific information in a specific format that allows the reader to gather information about each aspect of the session.
S – Subjective
O – Objective
A – Assessment
P – Plan
These four sections remind mental healthcare providers of the information they must collect when creating an appropriate care plan or treatment. This strategic template also allows healthcare providers to find the required information quickly and recall essential details when needed.
How to write a SOAP note:
Subjective – This part will contain the relevant information revealed by your clients in the session. This could be your client’s core complaint, presenting the problem and any relevant information. This information may include direct quotes from your client. This section also includes things discussed during your session.
Objective – The objective section contains any factual information. Such objective details may include things like a diagnosis, vital signs or symptoms, the client’s appearance, orientation, behaviours, mood or affect.
Assessment – This section is the place where you, as the healthcare provider, document your impressions and interpretation of the objective and subjective information. These clinical notes may include clinical impressions related to factors such as mood, orientation, risk of harm as well as an assessment of progress towards goals.
Plan – This section documents what the next step is for your client. What do you, as the healthcare provider, plan to do with your client during the next session? This is also the place to document things like the anticipated frequency and duration of therapy, short and long term goals as well as any new goals. Be sure to note any homework assignments or tasks you’ve given your client.
Do keep in mind that your clinical notes written in a SOAP template are not written for your clients. Remember to use the appropriate healthcare provider facing terminology.
The clear structure of SOAP notes increases the accuracy of your notes in general. Rather than trying to remember everything that happens in an appointment and jotting it down stream-of-consciousness style, SOAP notes give you a way to structure your sessions so you can get the right information at the right time, making it easier to recall and accurately input all the necessary notes.
Happy note taking!