Basic Soap Note Template for Healthcare Professionals

What are SOAP notes/forms?

‍SOAP notes are a widely used clinical documentation format that allows healthcare providers, professionals, and clinicians to capture client information. With the SOAP notes forms, practitioners can ensure valuable information is presented in a way easily interpreted and understood by others. 

Using progress notes, healthcare professionals can assess patients and their current condition subjectively and objectively to provide the best care. A SOAP note format analysis can contribute to collecting systematic electronic health records within the healthcare sector. 

Assessing the patient through SOAP enables the formulation of an effective treatment plan and allows for reviewing any current treatment. SOAP is a great way to organize and structure clinical records and effectively convey patient information.

What should be included in a SOAP note?

Multiple aspects must be included to create practical SOAP notes, including the four main components. To simplify this, we have summarized the core factors:

• Subjective (S): This section focuses on the client's experience and understanding of their perception. Subjective notes, including verbatim quotes, help paint a picture of the patient's feelings, symptoms, and progress toward treatment goals. 
• Objective (O): This refers to the practitioner's observations concerning the patient's medical information, evaluations, tests, x-rays, historical data, medication, and vital signs. It is factually based and free from clinician impressions. 
• Assessment (A): This summarizes the subjective and objective sections and is a directional section focusing on progress toward a treatment plan. It evaluates the client's current state and notes their diagnosis and any changes, all used in the next section. ‍
• Plan (P): The final section of SOAP notes is to derive a treatment plan based on the client's previous observations and current treatment plan or state. A course of action, with measurable goals specifically listed, is finalized to treat the patient.

We will provide you with more information and examples in the next section so that you can provide quality patient care. 

What should be included in a SOAP note?

Multiple aspects must be included to create practical SOAP notes, including the four main components. To simplify this, we have summarized the core factors:

• Subjective (S): This section focuses on the client's experience and understanding of their perception. Subjective notes, including verbatim quotes, help paint a picture of the patient's feelings, symptoms, and progress toward treatment goals. 
• Objective (O): This refers to the practitioner's observations concerning the patient's medical information, evaluations, tests, x-rays, historical data, medication, and vital signs. It is factually based and free from clinician impressions. 
• Assessment (A): This summarizes the subjective and objective sections and is a directional section focusing on progress toward a treatment plan. It evaluates the client's current state and notes their diagnosis and any changes, all used in the next section. ‍
• Plan (P): The final section of SOAP notes is to derive a treatment plan based on the client's previous observations and current treatment plan or state. A course of action, with measurable goals specifically listed, is finalized to treat the patient.

We will provide you with more information and examples in the next section so that you can provide quality patient care.

Diving deep into SOAP sections

Let's dive into SOAP sections, exploring each part to understand how they work together.

What does the S stand for in SOAP notes?

The subjective (S) section focuses on the client's experience and emphasizes their feelings, needs, and perception of their symptoms. The best way to capture this is to include verbatim patient quotes, with their exact wording, so as not to misinform other healthcare professionals who may review the notes.

Subjectivity allows clinicians to compile a firsthand document of what the client wants to achieve based on their current state. It enables fellow contacts to comment if needed. It provides a clear picture representing the client's experience. It reduces the risk of miscommunication by prohibiting paraphrasing and making statements without primary evidence.

What does the O stand for in SOAP notes?

The objective (O) section focuses on the client's factual observations. This mainly concerns quantifiable measurements and evaluations, assessments, tests, x-rays, medical or medication information, or noting relevant vital signs. 

Typically, the objective statement provides evidence for symptoms rather than relying on the client's experience. What is observed could contradict or confirm information seen in the subjective section. Still, it is used to aid clinicians in developing a treatment plan based on facts. 

What does the A stand for in SOAP notes?

The assessment (A) section synthesizes the subjective and objective sections to develop an effective treatment plan. 

Assessment allows for a general commentary on the client's state. It evaluates prior evidence to provide a clear picture of a definite diagnosis and care plan. Its systematic nature means that any underlying issues can be identified, enabling a big-picture perspective of how the client is doing with their available resources. It provides clinicians with the opportunity and starting point to think of alternate ways to help patients through a comprehensive evaluation of their state. 

This assessment is relatively straightforward with more commonplace psychological issues, whereas, with others with high comorbidity, this may take longer. 

What does the P stand for in SOAP notes?

The final plan (P) section is where the assessment and analysis of observations come together to define the patient's next course of action. 

The plan establishes a direction for the patient and either amends the current treatment plan or creates a new one that addresses their identified healthcare issues. This could involve changing medication, activity, or overall goals. It is helpful to include the rationale behind the currently administered treatment, the patient's response, and when the next session will be. To encourage productivity, it is also essential that the plan section incorporates specific goals to present a clear plan to the client. 

Example of a complete SOAP note

Examine this comprehensive SOAP note. Each section is labeled to facilitate easy identification of its components.

• Subjective: Maia states she is "feeling okay; some days are better than others." Her depressive symptoms fluctuate but seem to be improving. Maia indicates that she still feels down, stating, "When I do feel low, it's more of a flat feeling, and I can now get myself out of it a little bit." She explains that her main concern is sleeping, as she only sleeps "for around 5 hours a night."
• Objective: Maia presented an upbeat demeanor. Her mood appears to be relatively stable, an improvement from the last session. Her voice expresses more variation, with a mildly reduced flat affect, and she seems to regulate her mood better. This is all despite her appearance, which indicates fatigue. Her sleep patterns are also disrupted based on her sleep tracking data. 
• Assessment: Maia has Major Depressive Disorder (MDD) and has a family history. She seems to respond well to current therapy and medication of 20 mg of sertraline once per day, improving symptoms from last week.
• Plan: Maia will continue to attend therapy next week as usual, and she will continue with her 20 mg of sertraline medication once per day. If symptoms do not improve within the next two weeks, we will reevaluate her options to increase the dose or use alternative medicines. I have worked through a sleep schedule plan with her. If this does not improve within the next two weeks, we will assess prescribing medication to alleviate this issue. 

This detailed SOAP note encapsulates the patient's healthcare journey, aiding in informed decision-making and continuity of care.

What is the difference between a SOAP note and a progress note?

While SOAP and progress notes are crucial in clinical documentation, they differ in scope. Here's a breakdown:

• Progress note: A broad term encompassing any documentation that tracks a patient's health status and treatment journey. Progress notes can be written in various formats, including SOAP notes.
• SOAP note: A specific structured format designed to organize information within a progress note. SOAP stands for Subjective, Objective, Assessment, and Plan. It provides a clear and concise framework for documenting a patient encounter.

Think of it this way: Progress notes are like envelopes, holding various types of documentation. SOAP notes are specific letters within that envelope, offering a structured way to communicate patient information.

Free SOAP note templates

There are many SOAP note examples online. But we have crafted and compiled SOAP note templates to help you better understand them. This guide also gives you a sneak peek of what some of them look like. Check them out below:

Example of a basic SOAP note

Example of a psychotherapy SOAP note 

Example of a physical therapy SOAP note example

Harness the power of SOAP notes with Carepatron

With their user-friendly structure encompassing all vital aspects of clinical documentation, SOAP notes have become a widely recognized standard in healthcare. Their clear formatting and focus on subjective data, objective findings, assessment, and plan ensure transparency and easy understanding for other providers involved in a patient's care. This structured approach fosters seamless collaboration and facilitates informed treatment decisions.

Carepatron empowers healthcare practices to leverage the benefits of a free SOAP note template. Our built-in templates make transitioning to this universal documentation method smooth and efficient. The clean user interface simplifies note-taking, while the transferable structure aligns perfectly with healthcare business management needs.

By integrating Carepatron's SOAP note functionality, your practice can ensure comprehensive, compliant documentation, ultimately contributing to the delivery of exceptional patient care.

Try Carepatron for free today!

FAQs

Are SOAP notes still relevant in the digital age?

Absolutely! While handwritten notes are declining, the SOAP format remains widely used. Its structured approach ensures clear, concise, and consistent documentation, which is crucial for effective patient care.

Where do medications fit within a SOAP note?

Medications can fit in multiple sections. Mention them in the Subjective if the patient reports medication use or side effects. The Assessment section is suitable to discuss medication effectiveness or potential interactions. Ultimately, clear and organized documentation is key.

Is there a specific SOAP note length requirement?

There's no set page limit. Strive for concise documentation while capturing all vital information. Most SOAP notes typically range from 1-2 pages, depending on the complexity of the patient's case and the session content.

What are the key benefits of using SOAP notes?

SOAP notes offer numerous advantages. They promote consistent and accurate documentation across your records, facilitating better care coordination between providers. Additionally, standardized templates save time and allow you to focus on patient care.

How do SOAP notes benefit mental health professionals?

SOAP notes are valuable in mental health settings as well. The structured format ensures clear communication of a patient's mental state, treatment interventions, and progress over time. This fosters collaboration with other mental health professionals involved in the patient's care.