As a therapist, there’s a variety of reasons why you want to take thorough subjective, objective, assessment and planning (SOAP) notes. You’ll be taking notes for a client’s electronic health record (EHR), which other healthcare providers will review. It’s critical to take accurate notes when different providers may be basing a client’s care on what you’ve written — your words have the potential to make a very big impact. Accuracy and reliability are especially important when it comes to mental health documentation.
In essence, SOAP notes are progress notes that help you keep track of how your clients will grow under your care. SOAP provides a framework that simplifies the process of note-taking and can make your documentation more thorough. Reviewing SOAP notes can also help you alter treatment plans and add goals along the way. Learn how to make the SOAP note-taking process more seamless for yourself and how it can benefit your clients.
The first element of SOAP note-taking involves subjectivity, which means, according to the National Center for Biotechnology Information, that the information in this section “comes from the ‘subjective’ experiences, personal views or feelings of a patient.” You’ll record what the client says about their symptoms, how they feel and what’s going on in their life. It’s not based on your subjective interpretation of what’s going on with the client.
In this section, it’s important that you record key points verbatim, writing things down using the client’s exact words. You don’t need to type out everything they tell you. However, when they’re speaking specifically about their symptoms, their feelings, what they want to get out of their visits with you and what’s happening to them, you should avoid paraphrasing. This ensures you create the most accurate picture possible of their condition. It also helps you determine an overall theme for the session, which you can use to guide the focus of later sessions or to determine behaviors or goals you want the client to work on between sessions.
The subjective section can also include a general overview of what you spoke about during the appointment — it’s not only a compilation of statements the client made to you. Include words like “discussed” and “reviewed” to ensure you have this information in your SOAP notes. Summarize the main topics of the meeting so you have a timeline of how the conversation transitioned from one point to the next.
In the objective portion of the notes, you write out your own factual observations about the client. This is where it’s important to know the difference between symptoms and signs. Remember that symptoms are what a client reports, and signs are what another person observes about the client. Using physical conditions as an example, back pain is a symptom because only the patient experiencing it can feel it; their doctor can’t observe it. A rash, on the other hand, is a sign because the doctor can observe it on the patient’s skin.
You’ll record the signs you see the client exhibiting in this section of your notes. Think about the physical facts you can observe about the client. You might record how the client is groomed, what their body language is like, how punctual they were, how they talk, and what their overall mood or the mood of the session is. You might also include the ways the client is oriented, such as whether they know what time and day it is.
It’s essential to write down these observations during the session; if you try to write them down later recalling from memory, you may forget to include some important details. Try to note any signs you see that might contradict or validate symptoms the client described in the subjective section. If they claim they’re feeling anxious, for example, you might look for physical presentations of this anxiety such as sweating, trembling or nervous fidgeting.
While you should write down the S and O portions of your SOAP notes during the client’s visit, you won’t complete the A and P portions of the notes while the client is in the office. You might not be able to complete very detailed forms of these notes until you’ve had several appointments with the client, either. This is because it can take some time to figure out what’s going on with the client and fully assess what their long-term needs may be.
In this section, you’ll review the S and O portions of your notes to record your impressions of your sessions with the client. For example, you might write down that it seems like the client understood the goals you both set. Think of it as sort of an analysis of the client’s bigger-picture situation, taking into account S and O and determining potential conclusions you can draw.
You might also make recommendations about a potential diagnosis in the assessment section. If you’re working with a client who has a more common diagnosis, such as depression or anxiety, you may arrive at a diagnosis with your assessment within several visits. However, more complex conditions could take longer to assess and diagnose.
Once you’ve completed S, O and A, it’s time to put your synthesis of these sections into action by figuring out what the client’s next steps should be, along with what you’ll address during their upcoming sessions. You’ll start formulating a full treatment plan for the client here, including what the treatment is, why you believe it’s necessary, the metrics you’ll use to measure progress, instructions to give the client and any reactions the client has expressed about their feelings regarding treatment.
If you think you may need time to design a plan because of a client’s complex case, you may want to create an interim plan for a few upcoming sessions as you work out the full treatment. This gives them some short-term goals to work towards so they can start making progress while you perfect their plan. All of the treatment steps should be actionable, and it should be clear what the progression of the steps will be in case other clinicians need to take over the client’s treatment.
Use These Tips for Effective SOAP Note-taking
Jot down notes that you’ll easily remember and add SOAP into the client’s EHR immediately after they leave. Allow 15 to 30 minutes between clients to manage this effectively and give yourself enough time to reflect accurately.
Be concise with SOAP notes. Don’t make them so clipped that you can’t understand them when you’re reviewing them later — but also keep in mind that they don’t need to be overly descriptive. Come up with and use your own abbreviations for ease while recording and better comprehension while reviewing later.
Avoid using others’ names when taking notes. If a client is referring to a spouse or other family member as they’re talking, use that person’s initials or the word “spouse,” for example, in your SOAP notes. This protects privacy should a colleague read your notes.
Lastly, avoid passing judgment or writing comments that sound judgmental in SOAP statements. Focus on direct accuracy. Make observations but remain professional and relay only what you see without using over-the-top descriptors. If a person is unkempt, for example, relay that they appear ungroomed instead of calling them “filthy.” Your wording should be neither overly positive nor overly negative.