SOAP Notes – Example, Template and Format
What is a SOAP note?The Subjective, Objective, Assessment and Plan (SOAP) note is an acronym represents a cognitive framework to help healthcare professionals organise treatment information of a client in a highly structured format.SOAP Notes template with exampleA SOAP note is structured into four parts;SubjectiveThis section focusses on the subjective experience of the patient or their caretaker. It includes the symptoms they are experiencing, feelings w.r.t. the illness, medical history, previous diagnosis (if any), and their personal views. Simply put, this is what the patient says about their problem.Example: 37-year old female presenting chest pain, decreased appetite and shortness of breath. Diagnosed with mild depression 1 year ago. Underwent psychotherapy for 3 months. Recent physical manifestations concurrent with family feuds.ObjectiveThe focus of this section is on objective data. This includes vital signs and symptoms, findings of the clinician, laboratory diagnostic data and objective reports from other clinicians. Unlike the “Subjective” section which gives a description of patient’s own account, the “Objective” section is backed by evidence. An example of this is a patient stating they have “stomach pain,” which is documented under the subjective heading. Versus “abdominal tenderness to palpation,” an objective sign documented under the objective heading.Psychological tests like , , etc. are particularly useful at this stage since they are objective in nature.Example: The client's results on the signals moderate depression, extremely severe anxiety and mild stress.It is recommended that you store the data in the client’s file securely in accordance with HIPAA . is a HIPAA compliant software you can use to conduct with your clients. It can help you maintain client notes automatically and save you tons of time.AssessmentThis section is the clinician’s analysis of the subjective and objective evidence to arrive at a diagnosis.For behavioral health practitioners, one would generally expect a differential diagnosis where they would list various problems in order of importance. At this stage, therapists could mention ICD-10 or DSM5 classification of the illness. This can be particularly helpful for therapists who are empanelled and accept insurance plans like United Healthcare, Aetna, BlueCross and BlueShield etc.Example: Client is most like suffering from Generalized Anxiety Disorder (ICD-10 code F41.1)PlanThis section details the treatment approach – interventions, goals/objectives of the intervention, expected time frame, and follow-up and next steps.Therapists could weigh various psychotherapy approaches like CBT, EMDR etc. at this stage to plan. Additionally referrals to psychiatrists can be considered to pharmacotherapy.In case, further information is required for planning the treatment, this section will include plan (additional testing, consultation with other clinician etc.) to obtain the required information.Example: Immediate initiation of pharmacotherapy and, if severe impairment or poor response to therapy, expedited referral to a mental health specialist for psychotherapy and/or collaborative management.DAP Notes and BIRP NotesSOAP notes are not the only format available for charting treatment. The other popular approaches include DAP (Data, Assessment, and Plan) and BIRP (Behavior, Intervention, Response, Plan). Among all these formats, SOAP notes format is most widely used.You should choose the format of documentation based on what’s best suited to your practice. But having a framework can be really helpful. “One of the biggest problems I see with new therapists,” says “is a lot of anxiety about how to write adequate professional notes. So many new therapists haven’t been adequately trained and carry a lot of anxiety about having their records audited. Following an official framework, like SOAP notes, can really help relieve that anxiety.” Additionally, you must be wary to not adjust your treatment to fit any particular format. Always remember, treatment notes follow the treatment and not vice versa.PsyPack Practitioner’s NotesAt , we are constantly working to ensure that therapists are empowered with technology to streamline their practice. Apart from helping you embrace evidence based approach by digitising a , we now allow you to add your own therapy notes to the assessment reports. You can now add notes in any format in the “Practitioner’s notes” section of reports. .Today the world is increasingly moving towards mandatorily maintaining treatment documentation. A part of this shift is to ensure best practices, choice of patient to switch their clinician, insurance empanelment and claim settlement etc. To stay competitive, it is critical to embrace best practices and technology in your therapy practice.
Team PsyPackMon Apr 11 2022