Introduction to Writing SOAP Notes with Examples (2024) | Carepatron

SOAP notes can be a powerful tool for simplifying your clinical practice. They provide a quick way to capture, store, and consistently interpret your client's information over time. Spending too long capturing progress notes can take up much time, energy, and resources for your healthcare business.

Without a framework, managing clinical notes can be challenging for healthcare practitioners, reducing the standard of your client's health records and practice management overall. A SOAP note template helps you capture the required information in clinical assessment consistently while also enabling your team to communicate the information they need when they need it quickly. This allows you to gain

What is the purpose of a SOAP note?

Before knowing how to write SOAP notes, it's essential to understand what they are for. SOAP notes are a clinical method healthcare professionals use to simplify and organize a patient's information. They record information consistently and structured using the SOAP note format. 

The SOAP note format helps health practitioners use their clinical reasoning to assess, diagnose, and treat patients using the information presented. SOAP notes are a critical information source for client progress and health status, and they serve as a communication tool for different health professionals. The SOAP note template structure can also be a checklist, helping practitioners capture information, especially during clinical examinations consistently.

This was first theorized by American physician Lawrence Weed more than 50 years ago. He wanted to provide clinicians with a template for specific tasks while providing a framework for evaluating information. Today, SOAP notes are considered the US healthcare standard for documenting clinical information across healthcare professions.

What is the SOAP note format?

SOAP is an acronym for subjective, objective, assessment, and plan. These are commonly used by mental health practitioners like psychologists and psychotherapists.

As mentioned, the SOAP note format provides a structured approach for documenting patient encounters in healthcare settings. It facilitates clear communication between healthcare providers and ensures comprehensive patient care. In this section, let's explore how to effectively write a SOAP note, outlining the key components and best practices for each section:

1. Subjective

The subjective section includes the patient's story – their experience of illness, concerns, and goals. It serves as the foundation for your clinical reasoning in later sections. Here's what you should document:

• Chief complaint: Briefly state the patient's primary reason for seeking care (e.g., "fatigue and difficulty concentrating for the past month" or "excessive substance abuse that has caused relationship issues").
• Patient's words: Use direct quotes to capture their perspective and needs (e.g., "I'm worried about keeping up with work"). This builds context and aids communication with other healthcare providers.
• Family/caregiver input: Include relevant information from family or caregivers who may offer additional insights.

Moreover, you can strengthen this section by anchoring your observations with objective details using the OLD CHARTS mnemonic:

• Onset, location, duration (OLD): When did symptoms start? Where are they located? How long have they been present?
• Characterization: Describe the nature of symptoms (e.g., sharp pain, burning sensation). Is it different from the baseline or normal limits?
• Aggravating/alleviating factors: What worsens or improves the symptoms?
• Radiation: Does the pain radiate to other areas?
• Temporal pattern: Is there a recurring pattern of the symptoms (e.g., daily or after meals)?
• Severity: How severe are the symptoms on a scale of 1-10?

In addition to these details, consider including:

• Past medical history: Briefly mention relevant past medical conditions.
• Surgical history (if applicable): Include significant past surgeries.
• Social and family history: Briefly mention pertinent social and family history details.
• Present illnesses: List any concurrent medical conditions. Are present symptoms consistent with this diagnosis?

Following these guidelines, you can create a comprehensive Subjective section that depicts the patient's experience.

Example

"David, a 62-year-old man, presented for his initial consultation reporting difficulty sleeping and a constant ache in his lower back. He stated, 'I haven't been sleeping well for months, and this back pain is making it even worse. I'm feeling exhausted all the time.'"

2. Objective

The objective section provides a clear picture of the patient's physical and mental state through measurable data gathered during your examination and any relevant lab data. This section works with the subjective section to create a holistic view of the patient.

Here's what to document:

• Vital signs: Record temperature, weight, blood pressure, and heart rate.
• Physical examination: Describe the patient's appearance, general health, and relevant physical findings.
• Mental status: Assess the clinical signs, including the patient's alertness, mood, affect, and cognitive function. It's also important to note whether there are indications of suicidal ideation.
• Behavior: Note the patient's behavior during the session, including communication style, engagement, and emotional expression.
• Functional abilities: Evaluate the patient's capacity to participate in daily activities.
• Tests and assessments: Include results of diagnostic tests, laboratory tests, or clinical evaluations.
• Medications: List all current medications prescribed and their corresponding dosages.
• External records (if applicable): Briefly summarize relevant information from medical records received from other healthcare providers, such as the client's chief complaint or present illness.

Remember to distinguish between symptoms (patient's experience) and signs (observable findings). Focus on factual and objective data, avoiding interpretations. Use clear and concise language throughout this section.

Example

The examination revealed normal vital signs (blood pressure: 130/80 mmHg, heart rate: 78 bpm, temperature: 98.2°F, weight: 185 lbs) with no acute distress. David was alert and cooperative, though somewhat fatigued.

During the session, the client presented slow movements, and he occasionally winced with discomfort, particularly when bending or twisting at the waist. Musculoskeletal examination revealed tenderness to palpation and limited range of motion in lumbar spine flexion and extension. Specifically, lumbar flexion was limited to approximately 40 degrees from neutral, and extension was limited to 10 degrees.

Strength testing of the lower extremities revealed no significant weakness (5/5 bilaterally on Manual Muscle Testing). David denied any history of falls or recent injuries to his back.

3. Assessment

In the assessment section, you analyze the information gathered in the subjective and objective sections to form a comprehensive picture of the patient's condition. Here's what you'll do:

• Synthesis: Integrate the patient's reported experience (subjective) with your clinical findings (objective) to arrive at a diagnosis. This will be an essential part of the patient records.
• Progress tracking: Evaluate the patient's progress toward treatment goals or identify areas needing further assessment, especially for complex cases.
• Differential diagnosis: Consider alternative explanations for the patient's symptoms if the diagnosis isn't immediately apparent.

This section informs your treatment plan summary, so it's crucial to:

• Monitor progress: Identify ways to track how patients progress through and respond to treatment or medication management.
• Plan adjustments: Consider potential changes in medication or treatment based on the assessment.

By effectively analyzing the information, you can create a well-founded assessment that guides your next steps.

Example

David's presentation of chronic sleep disturbance, constant low back pain, wincing with movement, limited lumbar flexion and extension (40 and 10 degrees, respectively), and normal strength testing suggest a musculoskeletal source for his pain, likely lumbar strain. To track progress, we'll use the Numeric Pain Rating Scale (NPRS) and Oswestry Disability Index (ODI).

While the lumbar strain is the leading diagnosis, disc herniation, spinal stenosis, or inflammatory conditions remain possibilities if symptoms worsen or don't improve.

4. Plan

This section outlines the treatment approach based on the information gathered in the subjective, objective, and assessment sections. You can detail the specific interventions to address the patient's concerns here.

• Treatment: Clearly define the planned interventions, including the type of therapy, medication adjustments (if applicable), or specific techniques used. Briefly explain the rationale for each intervention to ensure the patient understands the approach.
• Frequency and duration: Specify the frequency and duration of the planned treatment (e.g., weekly therapy sessions for eight weeks). This provides a clear roadmap for the patient's progress.
• Reassessment and follow-up: Outline the plan for monitoring progress and making adjustments. This might include tests for further exploration, scheduling follow-up appointments, and utilizing standardized assessment tools to track improvement objectively.
• Patient education and resources: Describe any educational materials or resources provided to the patient to support their treatment goals (e.g., relaxation techniques handouts, online support groups). Empowering the patient with knowledge promotes active participation in their recovery.
• Collaboration (if applicable): If necessary, outline any cooperation with other healthcare providers involved in the patient's care. This ensures a coordinated approach to treatment across disciplines.

The plan section uses clear and concise language and focuses on actionable steps. It guides the patient's care, facilitates communication within the healthcare team, and tailors the treatment plan to the patient's needs and goals. You can also consider potential barriers to treatment and address them in the plan to maximize the patient's success.

Example

A multimodal approach will target David's lower back pain and sleep difficulties. We'll initiate physical therapy to improve lumbar spine mobility and core muscle strengthening. Additionally, heat therapy or massage therapy can be used for pain management. To address his sleep issues, we'll implement sleep hygiene education and relaxation techniques.

We'll reassess David in two weeks to evaluate his response to these interventions. Depending on his progress and the presence of any red flag symptoms, further evaluation with imaging studies (X-ray or MRI) may be necessary.

SOAP notes can also be used in other fields. For instance, we also have SOAP Notes for Physical Therapy Template and SOAP Notes for Occupational Therapy Template.

Common pitfalls in SOAP note writing

Effective SOAP notes rely on clear communication and accurate documentation. Here are some common mistakes to steer clear of:

• Repetition: The assessment section shouldn't be copied and pasted from the subjective and objective sections. Analyze and synthesize subjective and objective information into a clear picture of the patient's condition.
• Real-time documentation: Give your client your full attention during sessions. Take brief notes with key points and quotes as reminders. Complete the SOAP note in your patient record software when details are fresh after the session.
• Emotional language: Maintain a professional tone and avoid judgmental language. Opt for neutral and objective wording that conveys accurate information.
• Privacy concerns: Protect patient confidentiality by excluding names of family members, other clients (especially in group settings), or anyone else the patient mentions. Consider using initials or numbers as placeholders. Remember, the SOAP note focuses solely on the patient you're documenting.
• Misunderstandings: To prevent misinterpretations, minimize acronyms and abbreviations. Establish a standardized list of abbreviations with your team for clear communication.
• Assumptions: Avoid words like "appeared" or "seemed" as they imply subjectivity. Focus on factual observations, clinical impressions, and what the client demonstrably does or says.

By avoiding these common pitfalls, you can create clear, concise, and informative SOAP notes that enhance patient care and ensure accurate documentation.

Best practices for writing SOAP notes

Following the SOAP format ensures clear communication and comprehensive patient care. Here are our top tips to maximize the value of your SOAP notes, regardless of your profession or clinical discipline:

• Leverage technology: Use SOAP note software to capture, store, and access patient information in the cloud. Explore free or cost-effective options if needed.
• Template power: Simple SOAP note templates can be a lifesaver if you don't have practice management software. It helps organize your thoughts and ensure consistent capture of critical patient information.
• Strike the right balance: Aim for SOAP notes that are concise yet informative, typically 1-2 pages per session. Most sections should be 1-2 paragraphs (up to 3 when necessary). This provides a complete picture without overwhelming healthcare professionals with excessive details.
• Security first: Remember, SOAP notes often contain sensitive health information protected by HIPAA regulations. Take necessary precautions to ensure data security and maintain control over this information.
• Purpose-driven documentation: Always keep the note's purpose in mind. SOAP notes inform other providers about a patient's status, progress, and treatment plan. They also serve as documentation for insurance purposes.
• Clarity for all: Write your notes knowing clients can request a copy. Maintain a concise and professional tone while ensuring clarity for healthcare professionals and patients.
• Complete documentation: Strive to create a SOAP note for every patient session. Consistent documentation gives a more complete picture of a patient's journey.

Following these tips, you can transform SOAP notes from a routine task into a valuable tool that enhances patient care, communication, and healthcare delivery.

Tailoring SOAP notes for telehealth encounters

The growing popularity of telehealth necessitates adjustments in how we approach SOAP note creation for virtual consultations. Here are some key considerations to optimize your documentation in this setting:

• Addressing communication delays: Telehealth platforms can introduce slight communication delays. To ensure you gather all necessary information, pause longer than usual after asking questions. This prevents unintentionally interrupting the patient and allows them to answer fully.
• Active listening and clarification: Don't hesitate to ask for clarification if audio or video quality is compromised. This ensures accurate capture of details for the Objective section.
• Objective assessment in a virtual setting: While physical examinations are typically limited in telehealth, maximize the information you can glean. Carefully observe the patient's behavior and appearance on camera and inquire about any physical limitations reported. Supplement this with other objective data sources, such as vital sign readings from home monitoring devices (if applicable).
• Enhanced note-taking: Telehealth sessions may require more detailed note-taking, especially regarding specific symptoms the patient reports. Since body language cues might be less apparent virtually, pay close attention to the patient's verbal communication and document descriptive details that might offer valuable insights.

Following these best practices, you can create comprehensive and informative SOAP notes for your telehealth sessions, ensuring accurate documentation and effective patient care delivery even in a virtual environment.

Mental health SOAP notes example

The following demonstrates SOAP note examples in clinical practice. This includes both progress therapy notes that a mental health professional can use.

Psychiatrists

Ms. M. states that she has "been doing okay" for the past week. Her depressive symptoms have improved slightly; however, the client's mood is still "low." Ms. M. says she is sleeping "well" and getting "7 hours sleep per night." She expressed concern about my note-taking, which caused her to be anxious during the session. She also expressed concern with occasional shortness of breath. 

Ms. M. is alert. Her mood is stable and improved, and she can regulate her emotions.

Ms. M. has a major depressive disorder with a family and social history. She also has a personal history of an acute stress disorder diagnosis.

Ms. M. will continue taking 20 milligrams of sertraline once daily. If her symptoms do not improve in two weeks, the clinician will consider titrating the dose up to 40 mg. She will continue outpatient counseling, patient education, stress management training, and self-care handouts.

Therapists

Subjective section

Mark states that he continues to experience cravings for methamphetamine, and he has considered dropping out of his treatment program to buy drugs "every single day." Mark is motivated to stay sober and says he's "sober, but still not enjoying it." Mark states, "I dream about drugs all the time, and I can't seem to quench my thirst," The client says he's "fit and strong overall."

Objective observations

Mark was present and engaged during the session. He does not display any signs of being under the influence or withdrawals. Mark remains aroused and distractible, but his concentration has improved. His ability to discuss his partner for fifteen minutes and reflect on his history indicated this.

Assessment of progress

Overall, Mark is making progress. He applies skills such as control techniques and exercises and is progressing in his treatment. His cravings have decreased from "every moment" to "every hour." However, Mark continues to experience regular cravings with a 10-year history of methamphetamine use. Mark needs to learn additional coping skills to manage his emotions. Considering the difficulty Mark faces, he may benefit from DBT treatment.

Plans for the next session

Mark has received patient education during his therapy sessions. The therapist will begin to use dialectical behavioral therapy techniques to address Mark's emotional dysregulation until a significant decrease in cravings is observed. He will also continue to hold family therapy sessions with his wife. Staff will continue to monitor Mark regularly.

Final thoughts

Mental health professionals and other healthcare professionals will spend less time creating better documentation with SOAP Notes. The best place to start is with free clinical documentation software or a SOAP note example you can refer to. High-quality SOAP notes can help your team save time, focus on patient care, and provide better health outcomes for their clients.

Transform how you provide care with our comprehensive practice management system designed for the demands of mental health practitioners. Get started by choosing Carepatron. Sign up for your free trial today!