The PsyPack Blog

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 PsyPack
Team PsyPack
Mon Apr 11 2022

Psychological assessments

Diversity is beautiful. But why does nature create each one of us so unique? We look different, we feel differently, we think differently, we behave differently and so on. In fact, no two of us have the same fingerprints!Why wouldn’t nature create all of us the same – something of “a standardised homo-sapien”?The challenge with such a high level of predictability is vulnerability. One adverse predator, one adverse virus, one adverse event could destroy the entire species. Diversity is not just beautiful but it is the essence of survival. Individual differences make us stronger as a species.One could imagine that since individual differences are so intrinsically linked to survival and nature, it makes studying them of immense value.Individuals vary in terms of physical characteristics, such as height, weight, strength, hair colour, and so on. They also vary along psychological dimensions. They may be intelligent or dull, dominant or submissive, creative or not so creative, outgoing or withdrawn, etc. The list of variations can be endless. Different traits can exist in varying degrees in an individual. In this sense, each one of us is unique as s/he exemplifies a typical combination of various traits.Behavioral health professionals and social scientists have devised multiple instruments over the years to study these differences scientifically. Psychological assessments help us study the amazing diversity in human beings and give us sneak peek into the mysterious ways of nature.What is a psychological assessment?All sciences are built on systems of constructs and their interrelations. The natural sciences use constructs such as temperature, gravity, and global warming. Likewise, the behavioral sciences use a variety of constructs or attributes. These can be very simple phenomena like time taken to react to a stimulus, i.e. reaction time, and also in highly global concepts like happiness. Behavioral health professionals study both non-psychiatric attributes, like intelligence, aptitude, interest, personality and values etc., and psychiatric constructs like depression, anxiety, somatoform disorders, Post-Traumatic Stress Disorder (PTSD) and Attention-Deficit/Hyperactivity Disorder (ADHD) etc. , a strong proponent of deliberate practice, recommends using outcome measures to improve clinical outcomes.Psychological attributes are not linear or unidimensional. They are complex and expressed in terms of dimensions. They are usually multi-dimensional. For example, if a child is having trouble in school, they might not fit strictly into a categorical diagnosis of a reading problem such as dyslexia, or an attention problem such as attention-deficit hyperactivity disorder (ADHD), or difficulty with impulse control? They might have different se­verity levels of the constituent symptoms of each of those. If you want to have a complete assessment of a person, you will need to assess how s/he functions in various domains or areas, such as cognitive, emotional, social, etc. With regards to diagnosis of mental disorders, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) favours the dimensional approach over the categorical approach.Assessment is the first step in understanding a psychological attribute. Assessment refers to the measurement of psychological attributes of individuals and their evaluation, often using multiple methods in terms of certain standards of comparison. Once assessment is done, we can use this information to predict future behavior of an individual. If the predicted consequence is not what we want, we may want to intervene to effect a change.The American Psychological Association defines psychological assessment as “the gathering and integration of data to evaluate a person’s behavior, abilities, and other characteristics, particularly for the purposes of making a diagnosis or treatment recommendation. Psychologists assess diverse psychiatric problems (e.g., anxiety, substance abuse) and non-psychiatric concerns (e.g., intelligence, career interests) in a range of clinical, educational, organizational, forensic, and other settings. Assessment data may be gathered through interviews, observation, standardized tests, self-report measures, physiological or psychophysiological measurement devices, or other specialized procedures and apparatuses.”Assessment MethodsPsychologists use several techniques for assessment;Characteristics of a good testAll measuring instruments, be it a measuring tape, a bathroom scale, medical tests like  X-rays or blood tests, or a psychological test must follow certain basic scientific principles to be any useful.ValidityA psychological test is useful only to the extent to which it actually measures what it purports to measure. For example, a test measuring a stable personality trait should not be measuring transitory emotions generated by situational conditions.There are multiple statistical methods of establishing validity;ReliabilityThe extent to which any measuring device (including a psychological test) yields the same result each time it is applied to the same quantity. For example, the measuring tape should not measure your height differently when measured by two different people. It must be consistent. Several different methods exist for assessing a psychological test’s reliability;NormsYou would never compare scores of two students from, say grade 5 and grade 10, on a mathematics test. Clearly, that would be unfair. Similarly, psychological constructs are also relative in nature. For example, constructs like intelligence are not absolute, but measure standing of an individual relative to a group. Test norms consist of data that make it possible to determine the relative standing of an individual who has taken a test. By itself, a subject’s raw score (e.g., the number of answers that agree with the scoring key) has little meaning. Almost always, a test score must be interpreted as indicating the subject’s position relative to others in some group. Norms provide a basis for comparing the individual with a group.To ensure fairness, it is essential that the norms used to assess an individual are based on a population which is representative of that particular individual.Ethics of assessmentsPsychological tests serve many useful purposes such as selection, counselling, guidance, self-analysis, and diagnosis. Unless used by a trained practitioner, they may be misused either intentionally or unintentionally. A practitioner is expected to follow certain ethics (or moral principles) while conducting the tests.The future of psychological testingWhile telemedicine and digital tools have become increasingly common over the past few years, the COVID-19 pandemic has super-charged and accelerated the adoption of telepsychology. Practice management tools like help psychologists, therapists, social workers and counselors to conduct not just likert scale assessments like , , etc. but also digital tasks based assessments like and .Startups like and are beginning to provide game-based psychometric evaluations to assess attention, decision making, risk tolerance etc., for the hiring process. ‘Gamified’ assessments are more engaging than traditional psychometric tests.Further the use of artificial intelligence (AI), including facial recognition and text analysis software, in psychometric assessments are promising in supplementing a clinicians’ efforts to spot mental illnesses earlier and improve treatments for patients. Computers could be trained to analyse a variety of data – mobility, physical activity, facial expressions, sleep patterns, typing behavior, body language and more. Apple is already working on iPhone features to help detect depression and cognitive decline. Although promising, these technologies first need to be shown to be effective. Additionally, some experts are wary of bias and other ethical issues as well.
Team PsyPack
Team PsyPack
Mon Oct 04 2021