What is a SOAP note?
SOAP note stands for Subjective, Objective, Assessment, and Plan. These notes are a form of written documentation that professionals in the health and wellness industry use to record a patient or client interaction. Since all SOAP notes follow the same structure, all your information is clearly laid out. That way, it’s easy for you and any other providers to easily read the note at a later date and immediately know what’s going on in a client’s treatment plan.
What should be in a SOAP note?
What should be in a SOAP note will depend on your specialty, who your client is, and what you’re working on during your sessions together. We’ve broken down the order of how you should write a SOAP note, and what should (and shouldn’t) be included.
S – Subjective
This section is for subjective reporting of your clients. It can include their mood, their reported symptoms, their efforts since your last meeting to implement your homework or recommendations, or any questions they have.
Start with the client’s history that has any relevant behavior. This can include:
Medical and mental history
Medications
Day-to-day routines
Complaints and/or problems
This section should not include:
Statements without supporting evidence
Unsourced opinions
Make sure any opinions or observations you include in the section are attributed to who said them, whether it’s yourself, your client, a parent, etc. Since this is a subjective section, you don’t want to pass off any of this information as fact.
O – Objective
This part of your SOAP note should be made up of quantitative, factual, and measurable data. This might include specific interventions used in the session, or measurable outcomes, like test scores, percentages of completion for goals worked on, etc. Examples include:
Client’s mental status
Physical and psychological observations
Relevant reports, like medical records or information from other specialists
Client behavior: how did they present themselves? Was there nervous talking or lack of eye contact?
This section should not include:
Personal judgements
General statements that don’t have supporting evidence
Assumptions pertaining to their behavior
Words or phrases that have negative connotations
Overall, this section should avoid general statements that don’t have supporting data. If you are discussing specific clinical interventions, why you chose that intervention and how it relates to the overall treatment plan should be made clear.
A – Assessment
Combine the S and O sections to create your official assessment. This section describes your interpretation of the session and your client’s progress towards their goals. You should include:
Your analysis of the subjective and objective information
Clinical and professional knowledge to interpret your client’s problems
DSM criteria/Therapeutic Model to identify the issues and treatment
This section should not include:
Repetitive statements from the previous sections
Make sure you don’t just repeat what you wrote in the S and O sections of your SOAP note. Take a step back and review your client’s progression (or regression) over time, and assess what factors may have contributed to this change.
P – Plan
The last part of your SOAP note should outline your plan for next steps, based on the problems you’ve identified. In this section, state any and all activities, objectives, or reinforcements that you’re changing. This can include:
Progression or regression the client has had
Next steps for upcoming sessions
How you’ll implement the treatment and next steps
Any physical, mental, or nutritional elements that could have an effect
This section should not include:
Rewriting your entire treatment plan
Goals that are immeasurable or unrealistic
If your client isn’t meeting the goals you’ve set, you don’t need to entirely change the treatment plan in this section. Rather, this section is for tracking progress, and making any necessary adjustments to the existing plan to help your client meet their goals.