An overview of SOAP notes
SOAP notes are a widely used progress note format that enables clinicians and healthcare professionals to capture client information consistently. They provide a quick way for practitioners to store and interpret patient data and smoother communication with fellow health teams. SOAP notes are commonly used for psychotherapy to record essential information efficiently as a form of medical compliance and security tools. The elements include:
Subjective (S) - Focuses on the client’s experience and perception of needs, symptoms, and progress towards treatment goals.
Objective (O) - Refers to the practitioners’ observations concerning patient medical information, vital signs, x-ray results, and evaluations or exams.
Assessment (A) - This is a summarised assessment of the available subjective and objective information and moves towards treatment plans and goals.
Plan (P) - The plan is the decided course of action between the practitioner and their client, comprised of measurable goals of their current status. This may involve assessments, follow-up activities, referrals, and changes in the treatment.
Why are SOAP notes important?
There are many reasons why SOAP notes are essential in being used as a primary note format for healthcare professionals. Not only do they make clinical data easy to understand and interpret, but they support practitioners by allowing a convenient way to record and gather information concerning clients. It allows for the subjective voice of the patient to be heard and noted while also allowing for objective, scientific observation of obvious symptoms that may present themselves in clients. Because it is a clear format with a highly adaptable template, healthcare professionals widely use it. This means they have a widespread familiarity that can be understood by a variety of specialists for internal consistency.
Do psychology therapists need SOAP notes?
Because of the seamless format that allows for subjective and objective observations, soap notes are commonly used in psychotherapy to assess mental health in patients.
What is a SOAP note in psychotherapy?
SOAP notes offer a clear format to document sessions with clients, particularly in psychotherapy. They enable Counselors, therapists, or psychotherapists, to make detailed and confidential notes regarding the patient’s personal experience. Psychotherapy healthcare professionals can make subjective and objective observations of the patient’s experience and note their initial impressions. As a form of therapy software, SOAP notes support therapists and clients to work together in psychotherapy. The practitioner can compose a treatment plan based on their observations, with the SOAP notes providing a solid overview for the psychotherapist to create the best-suited treatment for patient needs.
Example of SOAP note in psychology
Subjective section
“I’ve been feeling extremely tired lately, and I find it hard to get out of bed most days. I don’t know how to describe it, but I don’t have the motivation to do anything. I feel like I don’t like forward too much anymore or enjoy stuff as I used to...I haven’t been using my meditation app recently either.”
Objective section
John has presented anhedonic symptoms, as well as expressing fatigue. Today, John has come to me with slow movements, eye bags indicative of described tiredness, and visibly is less energetic than previous sessions. He seems to show mild signs of flat affect and confirms with his health app; his sleeping patterns reveal more sleep than usual.
Assessment section
John seems to be making backward progress. This is his third session, and he seems to present more depressive symptoms than usual, which are now of concern. He appears to be fatigued, has a loss of motivation in addition to a loss of interest. This is also reflected in his change of sleep, and so when weighing this evidence, John may benefit from receiving medication.
Plan section
John would benefit from being forwarded to a psychiatrist for further testing, and more importantly, to evaluate potential medication options for him. Medication may help alleviate his symptoms in addition to psychological therapy. I will put him through to Dr. Wilson, as John agrees this could be beneficial to him.
5 Tips for writing highly efficient SOAP notes in psychology
To write effective psychology SOAP notes, multiple factors need to be considered to ensure rich information can be extracted from patients and displayed in a simple format. This way, resulting treatment plans are designed with patients’ needs in mind and interpreted well by other healthcare professionals.
Timing is everything - Ideally, SOAP notes are filled in following the session with a patient. During the session, making personal notes is good to keep track of observations. However, SOAP notes allow for more detail. This allows for the consolidation of perceptions from the session and to have a more solidified treatment plan. Waiting too long could mean omitting important insight needed to treat the patient.
Write professionally - Avoid slang, colloquialisms, abbreviations, and informal language to maintain professionalism and a clear tone for other healthcare professionals. This allows insight to translate strongly and in an intelligible way for other clinicians to understand. Misunderstanding SOAP notes could lead to ineffective treatment plans and potential misdiagnosis of the patient’s condition.
Stay neutral - Observing clients is a scientific process that is free from judgment and assumptions. Avoid using loaded phrases or emotive language to accurately represent the patient’s experience and maintain an objective stance. Again, using especially connotative language could over or under-represent specific symptoms, which does not capture the patient’s needs.
Make sure your details are accurate - Sometimes, grammar is sometimes essential, as your notes will be more transparent and easier to follow when using correct pronouns, quotation marks, and the proper tenses. This means other healthcare professionals can interpret your observations well, and having the correct facts means getting the patient the best treatment.
Master an accepted correcting procedure - We’re all prone to mistakes. However, it is good to ensure that errors are corrected properly. If a mistake is made, refrain from using white-out or scratching it out completely. Using a strikethrough method means that others can see what you have corrected in the process to ease suspicion, and it is helpful to write ‘error’ along with initials next to it. This way, others can see the original, the corrected information, and who made the updated information.
SOAP notes examples for social workers
SOAP notes are also an excellent tool for social workers to make observations, and thus treatment plans, in a clean format that is easy for others to understand.
Subjective
Lucy states she has been feeling “pretty good” lately and has been able to exercise regularly, as well as attend social events. She says she has been actively implementing our previous plans and has also found a meditation app helpful.
Objective
Lucy saw me today and was upbeat. She did not appear stressed, tired, or concerned. She has been making good progress as her health apps show more physical activity and less screen time on the phone. Lucy seems to be taking on board the productive approach in the past couple of weeks and appears to have made significant improvements.
Assessment
Lucy appeared relaxed, with her speech normal in rate and volume. Her body language expresses more fluidity and is very open. This indicates improvement in junction with her descriptions and virtual health tracking. As she saw me today, there were no concerning signs of her anxiety.
Plan
Please plan to meet in another two weeks to see her condition. Because we have worked together for a while, it seems she is improving and that we could begin to implement more spaced-out sessions. She has our plans with her and will continue to work on them in hopes this upbeat nature will become more frequent.
Wrapping up
Psychotherapy SOAP notes are a great and effective way to communicate patient observations, and they present a clear format to assess and formulate treatment plans. It allows for a transparent, linear process from meeting with a patient to implementing treatment plans that are ideal for them. SOAP notes incorporate both subjective and objective observation and an initial assessment with the following treatment. Because of its widespread use, fellow healthcare professionals and clinicians are also familiar with its format, allowing straightforward interpretation of a patient’s condition.
Various software platforms, such as Carepatron, already incorporate SOAP notes templates to provide opportunities for practices to integrate them into their business seamlessly. Practitioners can store SOAP notes online in one place, with the platform also providing a high degree of security to ensure patient information is kept private. SOAP notes are an effective tool of the future that prioritizes user needs, and transitioning to their format will prove highly beneficial for healthcare workers.
One SOAP note template for practitioners and their clients: Try Carepatron for free today!
Further reading:
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