Documentation is never the main draw of a helping profession, but progress notes are essential to great patient care. By providing a helpful template for therapists and healthcare providers, SOAP notes can reduce admin time while improving communication between all parties involved in a patient’s care.

In a few sections, we’ll give a clear overview of how therapy SOAP notes are written, along with helpful templates and software you can use to streamline the process even further. If you’re looking for a more efficient, concise way to document your telehealth sessions, this helpful guide will be of value.

How To Write Therapy SOAP Notes

Therapy SOAP notes follow a distinct structure that allows medical and mental health professionals to organize their progress notes precisely.[1]

As standardized documentation guidelines, they help practitioners assess, diagnose, and treat clients using information from their observations and interactions.

Importantly, therapy SOAP notes include vital information on a patient’s health status; this can be shared with other stakeholders involved in their well-being for a more informed, collaborative approach to their care.

The S.O.A.P Acronym

SOAP is an acronym for the 4 sections, or headings, that each progress note contains:

  1. Subjective: Where a client’s subjective experiences, feelings, or perspectives are recorded. This might include subjective information from a patient’s guardian or someone else involved in their care.
  2. Objective: For a more complete overview of a client’s health or mental status, Objective information must also be recorded. This section records substantive data, such as facts and details from the therapy session.
  3. Assessment: Practitioners use their clinical reasoning to record information here about a patient’s diagnosis or health status. A detailed Assessment section should integrate “subjective” and “objective” data in a professional interpretation of all the evidence thus far, and
  4. Plan: Where future actions are outlined. This section relates to a patient’s treatment plan and any amendments that might be made to it.

A well-completed SOAP note is a useful reference point within a patient’s health record. Like BIRP notes, the SOAP format itself is a useful checklist for clinicians while documenting a patient’s therapeutic progress.[2]

In the next section, you’ll find an even more in-depth template for SOAP notes that can be used in a wide range of therapeutic sectors.

Therapy SOAP notes include vital information on a client’s health status; this can be shared with other stakeholders for more informed, collaborative patient care.

3 Helpful Templates and Formats

With a solid grasp of the SOAP acronym, you as a practitioner can improve the informative power of your Progress Notes, as well as the speed with which you write them.

This generally translates into more one-on-one patient time, reduced misunderstandings, and improved health outcomes overall – so the table below should be useful.

SOAP Notes: A Step-By-Step Guide

Podder and colleagues give a great overview of the different subsections that a SOAP progress note can include. Based on their extensive article, we’ve created the following table that you can use as guidance in your work.[1]

Details

Subjective

E.g. Patient observations, opinions, experiences

Subjective data from stakeholders and patients create a context for the Assessment and Plan sections that follow.  Example subsections include:

  • Chief or Primary Complaint, e.g. their condition, symptoms, or historical diagnoses
  • History of Present Illness, often further structured into onset, location, duration, characterization, alleviating and aggravating factors, radiation, temporal factors, and severity (OLDCARTS)
  • Patient History, including medical, surgical, family, and social factors
  • Review of Symptoms, which includes pertinent questions about potentially unmentioned symptoms, and
  • Allergies and Current Medications.

Objective

E.g. Test results, Experience Sampling Data

Wherever any tests or factual data are collected, they should be recorded along with subjective information for a more thorough analysis of the client’s condition.

Assessment

E.g. Mental health conditions, medical diseases

An integrated analysis of the combined objective and subjective data to offer a diagnosis. Where an existing condition is the reason for a mental health program, it will relate to changes in status.

  • Diagnosis/Problem: E.g. Generalized Anxiety Disorder, Repetitive Strain Injury, etc.
  • Differential Diagnosis: If applicable, other potential diagnoses are noted along with the practitioner’s rationale for suggesting them.

Plan

E.g. CBT, exercise programs, mental health coaching

A detailed description of any further actions that need to follow from the therapy, e.g.:

Occupational Therapy SOAP Notes

In Occupational Therapy, a SOAP Progress Note might include the patient’s injuries and their severity, home exercises, and their effectiveness.

Based on observations and interaction with their client, an OT professional might adjust their treatment program accordingly.[3]

Laid out in the S, O, A, P format, they might look like this:

Details

Subjective

On Tuesday, Elsie presented with 6/10 elbow pain after falling down the stairs 2 weeks prior. She reports implementing her mobility exercises twice each day and that she is now able to flex her elbow with an 80% range of motion.

Elsie seems enthusiastic about the exercises and her improvements but has acute pain when lifting objects over 5lb. She has ceased taking ibuprofen as the pain stopped on Tuesday.

Objective

Enhanced weight-bearing capacity and range of motion in her elbow confirm the strength- and flexibility-building exercise plan is having a good effect. 

Assessment

Increase dumbbell exercises to exercise regime to increase elbow strength.

Plan

Reduce session frequency from 2x week to fortnightly while monitoring improvement.

Applied Behavior Analysis SOAP Notes

SOAP notes also play a valuable role in Applied Behavior Analysis, by allowing professionals to organize sessions better and communicate with a client’s other medical professionals. Legally, they may also accompany insurance claims to evidence the service being provided.[4]

It is important to remember that ABA SOAP notes, as psychotherapeutic documents, must be stored privately. They may form part of a client’s overall medical file other therapy notes.

Details

Subjective

This section details where the session took place, who was present, and their reports of the client’s behavior.

E.g. The client appeared tired during today’s home visit. George reported a decrease in unnecessary handwashing behavior from 5x daily to 3x. His caregiver reports he has begun talking loudly in his sleep and seems more agitated during the day.

Objective

Objective data such as frequencies, accuracies, and duration of specific behaviors are outlined here, using relevant frameworks (e.g. Antecedent, Behavior, Consequences).

I.e. Increased anxiety-related symptoms as measured by Subjective Distress Scale, cleaning chair for 10 minutes before sitting

Assessment

Assessment notes should include evaluations of the current program’s efficacy, describing particular strategies and targets.

E.g. Further increase Cognitive Restructure exercises to positively reinforce desired behavior.

Plan

This section describes any amendments that will be made to the client’s treatment plan

E.g. Increase home ABA visits from 2x weekly to 3x weekly. Teach Mindfulness Meditation module to George over 4 days.

These illustrative Occupational Therapy SOAP Notes and ABA SOAP Notes also exemplify how versatile SOAP notes can be.[5]

It’s why the framework is a commonly used standard in sectors such as Physical Therapy, Nursing, Rehabilitation, Speech Therapy, and more.

5 Examples of Effective Note-Taking

Many therapy software systems help to speed up the documentation of progress notes through in-built templates and diagnostic codes. At the end of the day, however, clinically valuable notes require careful thought and judgment when it comes to their content.

Effective notes are generally:[3][6]

  1. Written immediately following a therapy session. This way, a practitioner’s in-session time is spent focused on patient engagement and care; writing notes immediately after helps minimize common mistakes such as forgetting details or recall bias.
  2. Professional. An important part of patient Electronic Health Records, SOAP notes should be legible and make use of professional jargon to serve as a common frame of reference. They should be written in the present tense.
  3. Concise and specific. Overly wordy progress notes unnecessarily complicate the decision-making process for other practitioners involved in a patient’s care. Brief, but pertinent information helps other providers reach conclusions more efficiently.
  4. Unbiased: In the Subjective section, particularly, there is little need for practitioners to use weighty statements, overly positive, negative, or otherwise judgmental language. SOAP notes are frequently used both as legal documents and in insurance claims.
  5. Utilize appropriate details, such as direct quotes: For a more comprehensive document that includes all the salient facts of an encounter.

An effective SOAP note is a useful reference point in a patient’s health record, helping improve patient satisfaction and quality of care.

3 Smart Software Solutions

In this section, we’ve reviewed three of the top practice management software systems offering helpful SOAP note functions.

These include SOAP note templates, discipline-specific codes, and treatment planning features that integrate with therapy progress notes.

Software

Details

My Clients Plus SOAP NotesMyClientsPlus is a mental health practice management solution that runs on the web, Android, and Apple platforms.

With a loyal user base and many e-therapy features for telehealth, MCP comes with SOAP note templates that can be easily shared in multi-provider organizations.

While it doesn’t offer robust treatment planning features, MyClientsPlus does include sector-specific templates and native support for telehealth sessions.

NameMyClientsPlus
Price$24.95+ monthly
Good ForMental Health Coaches, Psychologists, e-Counselors, Therapists, Customer Relationship Management
Websitehttps://www.myclientsplus.com/

Software

Details

Clinicsource SOAP Notese-Counselors, physical therapists, speech therapists, and other practitioners creating SOAP notes will likely find value in ClinicSource SOAP templates.

The software allows quick progress notes to be created, and these can then be centralized with a client’s records, alongside their billing history and summaries from each visit.

Other features of this therapy notes software include Treatment Progress templates, Patient Evaluation templates, and features for building Care or Treatment Plans.

NameClinicSource
Price$59+ monthly
Good ForMental Health Coaches, Psychologists, e-Counselors, Therapists
Websitehttps://clinicsource.com/

Software

Details

Power Diary SOAP NotesPower Diary has a sizable library of mental health forms that counselors, psychologists, and therapists can use to create treatment plans.

SOAP and other session notes can be imported, exported, cloned, or shared to reduce admin time and centralize client records into one handy profile.

Despite lacking some of the more robust mental health capabilities, such as e-prescribing, it has a low price tag and is easy for first-time clinic software users to navigate.

NamePower Diary
Price$5+ monthly
Good ForSpeech Therapists, Psychologists, e-Counselors, Physical Therapists, Occupational Therapists, Mental Health Coaches
Websitehttps://www.powerdiary.com/

Final Thoughts

With clear, consistent information on a patient’s health status and progress, therapists, psychiatrists, and counselors are much better equipped to manage their well-being. And while note-taking may not be glamorous, harnessing the right software can significantly reduce the time you spend on this vital part of healthcare.

SOAP notes play a pivotal role in streamlined, effective healthcare, and are a daily part of life for many practitioners. If you’ve tried and enjoyed using any particular templates, forms, or therapy notes solutions, let us know in a comment.

References

  1. ^ Podder, V., Lew, V., & Ghassemzadeh, S. (2020). SOAP Notes. StatPearls. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK482263/
  2. ^ Sando, K. R., Skoy, E., Bradley, C., Frenzel, J., Kirwin, J., & Urteaga, E. (2017). Assessment of SOAP note evaluation tools in colleges and schools of pharmacy. Currents in Pharmacy Teaching and Learning, 9(4), 576.
  3. ^ Fusion Therapy. (2020). How To Write Therapy SOAP Notes.. Retrieved from: https://blog.fusionwebclinic.com/soap-notes-for-occupational-therapy
  4. ^ WebABA. (2020). Simple Guidelines for Writing SOAP Notes. Retrieved from https://webaba.com/2020/07/01/aba-practice-daily-simple-guidelines-for-writing-soap-notes/
  5. ^ Belden, J. L., Koopman, R. J., Patil, S. J., Lowrance, N. J., Petroski, G. F., & Smith, J. B. (2017). Dynamic electronic health record note prototype: seeing more by showing less. The Journal of the American Board of Family Medicine, 30(6), 691.
  6. ^ Purdue University. (2020). Tips for Effective SOAP Notes. Retrieved from https://owl.purdue.edu/owl/subject_specific_writing/healthcare_writing/soap_notes/soap_note_tips.html

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