How to write a soap note: full guide
How to write a soap note: full guide
Recording progress notes is crucial in the behavioral healthcare profession. The notes record specific information and aspects about a client and guide. Soap notes are, however, not part of the curriculum. This article is a guide on how to write a soap note.
Soap notes include relevant client behavior status, observable, quantifiable, and measurable data, analysis of the information given by the client (assessment), and an outline of the course of action(planning). Soap notes should remain in a client’s medical record.
Soap content
SOAP or subjective, objective, assessment, plan notes allows for continued documentation of a patient’s encounters in a structured way. Below is the soap format to use when writing a soap note.
Subjective
This is a statement about a client’s behavior.
As a nurse, you enter the client’s primary complaint, chief problem, and any other pertinent information, including any quotes by the patient. At the same time, include personal issues or any medical issues that affect or impact the client’s daily activities.
Contains an account of the patient’s symptoms description.
Contains the patient’s improvement from the last visit.
What content to include:
Quote directly what the client says. For example, Mary states: ” I have a migraine, and I didn’t sleep well last night”. We discussed more symptoms she may have to establish the cause of the migraine.
Mary reports frequent migraines and occasional anxiety in the past week and says, “I am anxious and get migraines out of nowhere. I don’t know where it is coming from”. During last month’s session, I remember Mary mentioning that she has been stressing a lot about some classwork. We talked about this being a possible cause for her current health state.
What to avoid:
Never include a statement that lacks supporting facts. Opinion statements need to be supported with facts for whatever observation you make. For example, if a client is unwilling to participate, state the indications that concluded that.
Consider the information and relevant statements from the patient, guardian, or family that can be attributed to the patient’s state, awareness, reasons, and unwillingness to participate.
When making subjective statements, always include pertinent evidence. For instance: the “patient appears disoriented as evidenced by her absentmindedness during the session”.
Objective
This is quantifiable, observable, and measurable data.
This part includes factual documentation about the patient: patient’s diagnosis, physical or behavioral symptoms, appearance, and mood.
How the client presented themselves based on your observations
Body posture
Verbal or non-verbal
Affect when discussing specific issues
Content to include:
General appearance
Physical and psychological observations
Behavior
Patient’s mental status
Patient’s strengths
Patient’s response to the process
Patient’s participation ability
Patient’s response to the process
Written material such as laboratory tests and reports from other providers such as psychological tests or medical records should be included here.
Content to avoid
General statements without supporting data
Assumptive statements
Personal judgments
Labels
Personal rather than professional opinions
Phrases with negative connotations
Assessment
When writing soap notes assessment, use acquired professional knowledge to interpret the patient’s information given during the session.
To understand patterns, execute clinical knowledge and understanding
Include DSM indicator observations exhibited by the patient
Content to include in soap notes assessment
The patient appeared unusually disoriented and exhibited excessive sweating and fatigue. A client presented pain in the eyes which the provider feels may contribute to the frequent migraines.
The patient appears to experience nasal pain before and after nose bleeding.
The client continues to experience anxiety.
The patient continues to express work-related stress
The patient expresses moderate depression
Content to avoid in soap notes assessment
Repeating your statements from the subjective and objective sections. Instead, include the patient’s progress, regression, or plateau in this section.
Planning
This section outlines the next course of action for the treatment based on the preceding.
Information gathered during the session:
Focus on the steps for the upcoming session. Keep to the agreed treatment plan
Focus on what was agreed
Note the factors contributing to the patient’s medical goal: physical, nutritional, and medical attributes.
Note any progress or regression a patient has made in the treatment
Implementation
It should be direct and aligned with the assessment
Content to include:
Focus on the patient’s symptoms and how they affect daily functioning; frequency, duration, and intensity
Build trust with the patient so that you can establish any other causes of their illness to come up with a better conclusion
The client is committed to meditation in their workout plan
The client will consult with a nutritionist for a healthy diet plan
Content to avoid
Restating the treatment plan instead of the next session plan
Unrealistic goals to be attained before the next session
Tips for completing SOAP notes
Find the appropriate time to write soap notes: don’t write notes while in session with a client.
Maintain a professional voice
Avoid using tentative language such as mayor seems
Avoid using words like good or bad or words that suggest judgment. Instead, consider how the patient is represented
Avoid using absolutes such as must, all, never, except, etc
Phrase use familiar to the mental health field
Uses culturally sensitive language
Proofread your notes
Use clear and concise language
Write notes you can defend its content
Whenever you quote the client, ensure you place the exact word in quotation marks.
Your notes are short and exact. Do not expand more than required in each section.
Use correct grammar
Avoid the use of positive or negative phrasing
Avoid pronoun confusion
Be nonjudgmental
Soap format
A well-structured format is easier to read and understand. It also makes it easier to get a glimpse of the document without reading every word. A standardized format facilitates the standardization of assessment methodology for an organized assessment process. Below is how to write a soap note format.
Use clear and concise language.
Clarity and conciseness ensure that anyone can read and understand the document easily.
Avoid jargon
Technical language and jargon limits accessibility by those who are not familiar with the terms
Be clear
Ambiguity makes it hard for readers to understand, which confuses and, in some cases, misinterprets the words. Use simple language and preferably use words with different meanings to avoid confusion.
Use active voice
Active voice is more assertive and crucial when making a solid point. It also makes your writing concise and easier to read. When conveying information to the patient, you should be clear. An active voice is essential in the report and relaying the plan for the patient.
Passive voice creates ambiguity and ensures that you don’t make a mistake. Transparency is essential.
Format notes for easy reading
Use headings, lists, and other formatting features to make your notes easy. Formatting prevents confusion and ensures that you write only the essential information fast and efficiently.
Use standard abbreviations
Standard abbreviations are universally understood abbreviations, and they make it easier for everyone to understand the documentation. It helps eliminate any confusion and misinterpretation.
Correct abbreviations are vital to legitimize the document. They equally save time. For those who might need the document for future assessment, ensure you use appropriate terms.
Proofread the work
To ensure that your [r document is clear, accurate, and concise, proofread to catch errors that might have slipped during the writing process.
Use a template
A soap note template helps standardize the document and ensures the document process moves quickly. Creating a template helps maintain consistency and reduce ambiguity.
Mental health soap note example
The soap format is the most commonly used method for writing mental health progress notes. This framework helps you capture the most critical information from a session using a clear structure. Below is an example of writing a soap note on mental health.
Client description
A client’s general presentation: Manner of dress, physical appearance, illnesses, and disabilities. Update this section after the first time session.
Subjective complaint
Presenting issues from the client’s point of view. What the client says are the cause, duration, and seriousness. If there is more than one concern, rank them based on their perception of the importance.
Objective finding
During the session, these are observations: verbal and non-verbal, body posture, eye contact, and tone of voice. Note any changes and why they occur.
Assessment of progress
What is your view of the client besides what they say? What is your evaluation based on emotional behavior and understanding? Identify patterns in what the client does or says. Use mental health models and include your hypothesis, interpretation, and conceptualization of the patient.
Plans for the next session
These are plans for the client. Outline short and long-term goals.Your interactions with the client and what you wish to tackle during the next session. What approach will you use? What do you base your plan on?
Soap note template
A soap note template is a note for what you will write while on the wards. The notes vary in length and content depending on the specialties. This article will guide you on how to get started.
There are short notes written to document the patient’s current status and those that detail the history and physicals usually written at the time of admission at the hospital. They are meant to pass on pertinent information concisely. However, this note is different from what you will be expected to do for your final paper. Below is how to write a soap note template:
Subjective:
Chief complaint
History of recent illness
Pertinent review of systems
Pertinent past medical history, family history, lifestyle, and social factors
Objective
Vital signs
Targeted physical exam findings
Medications and allergies
Diagnostics tests that have already been completed
Assessment
Differential diagnosis: with likely order with probable etiologies
Plan
The proposition of treatment for each diagnosis
Psychotherapy soap note example
Subjective
Mary reports that she is “feeling good” and enjoying her time. Mary says that she has been compliant with her medication and has incorporated yoga whenever she feels anxiety.
Objective
Mary could not attend a session as she sits for her final exam this week. She was able to get in touch over the phone, and she is willing and able to make a call at the set time. Mary sounded calm and positive over the phone.
Assessment
Mary presented this morning with a relaxed mood. She was articulate in her thoughts
and her speech was every day in tone, rate, and volume
Plan
The plan to meet in person at 11 is next Thursday. 2nd November. Mary will continue with her current medication.
Soap notes social work.
Subjective: this portion of soap progress notes for social workers is where the client explains their problem(s) in their own words. This subjective part may also include information provided by another party close to the situation.
Objective: the objective part of the process notes social work professionals write based on facts that are not subjective. This can be dating a specific event that happened or started. Objective case notes for social work can also include the observation of the social worker. The observation should be unbiased and nonjudgmental.
Assessment: in this part, the social worker takes the subjective and objective information and uses that to provide uses it to provide their assessment of the situation. This area of soap report will include the conclusion of the issue and the recommendations on the measures and direction to take.
Plan: this is the final section, and it includes the details of the care plan of action. This should consist of any referrals to other agencies and any goals and timeline targets. This area is vital because it dictates the steps to be taken to assist the client with their needs.
Psychiatric soap note
There have been debates about the relevance of soap notes due to the complexity of medical care. However, this documentation method continues to be helpful in mental health transcription services as a practical option to maintain timely, effective, and meaningful soap notes.
Soap note structure in mental health
Below are the main aspects that need to be included in a soap note in behavioral health.
Subjective
The first heading of a psychiatric soap note describes the patient’s personal views or comments from someone close to them. Additionally, to the chief complaint, you should document medical and family health history
Objective
This section covers the objective data collection during the patient encounter. The data includes vital signs, physical exam findings, laboratory test and imaging results, and other diagnostic information.
It also includes any review documentation of other clinicians. The objective soap note in the mental health assessment relates to how the body functions and assesses neurological functioning.
Symptoms are typically documented in the subjective section but signs in the objective area. Symptoms are the patient’s condition description, while signs are the symptoms you observe.
Assessment
This section contains your impression and interpretation based on the information documented in the subjective and objective areas. The primary purpose of the assessment is to arrive at a diagnosis. If the condition is complex and requires more accurate and personal data, the first visit may not include a diagnosis.
List possible and different diagnoses in order of importance from most to least likely, along with the diagnostic process’s decision-making. The assessment includes the most pertinent information only.
Plan
The above three sections are brought together by the plan, formulating the treatment plan and any other treatment steps. It enables future providers to understand the course of action. The plan should have action taken for each diagnosis. If a patient has multiple concerns, you write separate pans for each diagnosis. Below is a list of what the plan follows:
The treatment administered in each session and its rationale
The patient’s immediate response to the treatment
Date of the next visit
Instructions are given to the patient
Goals and outcome measures for new issues being re-assessed
Soap progress notes
With an understanding of how to write a soap note, you know how to write soap progress notes. Progress notes are made in a chart to record interactions between you and your patients. Documentation is never the primary purpose, but progress notes document interactions during patient visits and discussions by phone or outside the hospital. Progress notes are essential for overall patient care.
There are many potential readers of a patient’s chart, including and not limited to patients themselves and insurance claim administrators. It is essential to use clear and concise language, avoid jargon and make your reasoning explicit.
Bottom line
Soap notes are essential as they provide you, the patient, and any other party with written proof of what you observed and did. This is crucial because it helps you keep track of goals. A well-completed soap note is a reference point within a patient’s record.
In some cases, your employer may require your notes or even an insurance administrator for reimbursement. A soap note proves what happens if your work comes under review or has to defend your document. Therefore, you must know how to write a soap note clearly and concisely.
