Learning how to write a SOAP note is essential for clinicians to document, assess, diagnose, and track client care plans. SOAP stands for Subjective, Objective, Assessment, and Plan.

Each letter represents a section in the document you’ll create with your notes. In this article, we’ll explore how to write a SOAP note, what to include in each section, and some examples to get you started.

 

What is a SOAP Note?

 

The SOAP note, developed in the 1950s by Lawrence Weed, a professor of medicine and pharmacology at Yale University, was originally called a problem-oriented medical record (POMR). It has since evolved and is now widely used across various healthcare disciplines, including mental health, to document and organize findings objectively.

 

Understanding how to write a SOAP note is crucial because, despite variations in specific information and length, they all follow the same basic structure. This standardization facilitates easy coordination of care among providers in different specialties.

 

How to Write a SOAP Note

 

How to write a SOAP note is straightforward due to its precise structure, though it does require practice. The acronym SOAP stands for:

 

• Subjective
• Objective
• Assessment
• Plan

 

The content you include under each heading will depend on your clinical specialty, the client, and the focus of your sessions. Below is a breakdown of how to write a SOAP note, with suggestions for what to include in each section.

 

Subjective

 

This section captures the client’s subjective reporting of their feelings and symptoms during the session. It may also include information from family members and past medical records.

 

Mental health practitioners often focus on the “Chief Complaint” (CC) or the presenting problem in this section. Even if multiple CCs are reported, identifying the most compelling issue is crucial for an effective diagnosis.

 

Key areas of inquiry to uncover the primary CC might include:

– History of present illness

– Medical history

– Review of systems

– Current medications

 

Questions to ask:

1. Describe your symptoms in detail. When did they start, and how long have they persisted?
2. What is the severity of your symptoms, and what alleviates or worsens them?
3. What is your medical and mental health history?
4. What other health-related issues are you experiencing?
5. What medications are you taking?

 

Ensure any opinions or observations are attributed to the source, whether the client or yourself. This section should not present subjective information as fact.

 

Objective

 

This section consists of physical findings gathered during the session. Examples include:

– Vital signs

– Relevant medical records or information from other specialists

– The client’s appearance, behavior, and mood during the session

 

Note: This section should only include factual information observed, excluding anything reported by the client.

 

Assessment

 

The assessment section synthesizes information from the subjective and objective sections, describing what you think is going on with the patient. Include your impressions, interpretations, and clinical knowledge of DSM criteria/therapeutic models to arrive at a diagnosis or a list of possible diagnoses.

 

Plan

 

The final section outlines your plan for the next steps in treating the patient. It can include short- and long-term goals, specific plans for the next session, and general expectations for the duration of treatment.

 

By following this structured approach, you can create effective and comprehensive SOAP notes that facilitate client care and coordination among healthcare providers.

 

How to Write a SOAP Note: Therapy SOAP Note Examples

 

Understanding how to write a SOAP note is crucial for social workers and behavioral health practitioners. Below are examples to help you create effective SOAP notes.

 

Therapy SOAP Note Example for Social Workers

 

Subjective:

Client reports increased anxiety this week, feeling jittery and on edge, and experiencing more uncontrollable anxious thoughts.

 

Objective:

During the session, the client was fidgety, wringing her hands, and speaking quickly. She had difficulty concentrating, often asking for questions to be repeated. The client expressed a fear of losing her job and housing despite acknowledging no imminent threat.

 

Assessment:

Based on client reports and session observations, the client’s anxiety has increased but still meets the criteria for generalized anxiety disorder (GAD).

 

Plan:

Recommend that the client see a primary care physician to rule out thyroid or other medical conditions. Continue weekly therapy sessions to treat anxiety with cognitive behavior therapy (CBT). Suggest practicing meditation and mindfulness techniques at home.

 

SOAP Note Example for Speech-Language Pathologists (SLPs)

 

Subjective:      

Client reports increased vocal demands due to additional work meetings. Colleagues noted improvement in her voice, but she still experiences intermittent vocal fatigue during social events. She has been practicing her semi-occluded vocal tract (SOVT) exercises three times daily.

 

Objective:

Client performed SOVT exercises with a straw in water, achieving optimal voicing in all attempts. Introduced conversational training therapy (CTT), with the client successfully differentiating between her “husky” and “presenter” voices. The client achieved a “presenter” voice in most practice phrases with moderate visual cues.

 

Assessment:

The client met goals of optimal voicing for vocational demands, showing improvement in vocal effort from 7/10 (somewhat hard) to 4/10 (somewhat easy). She is progressing towards applying SOVT strategies in social settings.

 

Plan:

Continue the current care plan, targeting optimal voicing in functional environments with CTT techniques. Introduce additional strategies to manage vocal load in both vocational and social contexts.

Example of how to write a SOAP note

 

Writing a SOAP note is crucial for healthcare professionals to document patient progress accurately. Below is an example of how to write a SOAP note, followed by some tips to help you master the art of SOAP note writing.

Example of how to write a SOAP note

Client Full Name: John Doe
Client Date of Birth: 06/12/1985

Date of Service: 13/07/2024
Exact start time and end time: 11:58 am – 3:45 pm: 3 hours

Session Location: Miami

Diagnosis: (F32.1) Major depressive disorder, single episode, moderate

Subjective:

During the session, John Doe reported significant improvement in his mood since our last meeting. He has been utilizing coping mechanisms discussed previously and engaging in enjoyable activities. His depressive symptoms have decreased in intensity and frequency. John Doe mentioned a recent family gathering where he felt more connected and supported, contributing to his improved mood. However, he expressed concerns about his sleep patterns, noting occasional difficulty falling asleep and early awakenings.

Objective:

John Doe does not present a risk to self or others. His affect was brighter and more animated than in prior meetings. He actively participated in the session, showing improved eye contact and verbal expression. His body language suggested decreased tension. John Doe’s energy levels have improved, and he reported regular physical activity such as walking and jogging. His mood was calm, and his affect was appropriate throughout the session.

Assessment:

John Doe has made significant progress in managing his depressive symptoms. The combination of psychoeducation on coping strategies and increased engagement in pleasurable activities has positively impacted his well-being. His affect, mood, and verbal expression have all improved, indicating a positive response to therapy. However, John Doe’s sleep disturbances warrant further exploration to identify and address underlying stressors.

Plan:

We will continue to reinforce and build upon effective coping strategies like mindfulness and behavioral activation. Additional attention will be given to John Doe’s sleep disturbances. We will explore potential triggers and stressors contributing to these issues and provide psychoeducation on sleep hygiene and relaxation techniques. Continued therapy sessions will aim to further improve his mood, manage depressive symptoms, and address his sleep concerns.

This document is for educational purposes only. Examples are illustrative and designed to facilitate compliance with payer requirements and applicable laws. Check with legal counsel or state licensing board for specific requirements.*

Tips for Writing SOAP Notes

• Time Management: Plan to spend 5 to 7 minutes writing each progress note. Fit them in between sessions to avoid accumulating hours of catch-up work at the end of the day. Efficient note-writing is crucial for your own self-care as a provider.
• Conciseness and Accuracy: Aim for comprehensiveness rather than length. Notes that are concise yet cover all necessary information are more effective than lengthy notes that miss key details.
• Focus on Essentials: For insurance purposes, document information that supports the client’s diagnosis and justifies the ongoing need for treatment. Avoid stressing over every detail; prioritize information that substantiates the therapeutic approach and treatment necessity.

 Using SOAP Notes with Practice Management Systems

 

Nursingbuddie.com is a HIPAA-compliant practice management writing service that simplifies note-taking with built-in templates for therapy notes, progress notes, and SOAP notes. This system allows you to quickly access and complete your notes after each session.

 

With nursingbuddie.com’s integrated SOAP note templates, you’ll never need to search for how to write a SOAP note again. The platform helps you stay organized and run a paperless practice efficiently.

 

If your EHR lacks built-in SOAP notes, you can download a template or create your own following the guidelines provided above. SOAP notes should document your findings clearly and be easy to refer back to, so use the format that best suits your practice.

 

Considering a switch to a fully integrated, HIPAA-compliant writing expert? Nursingbuddie.com offers everything you need to streamline your note-taking process. Use the template library, update notes quickly with the “load previous note” feature, and send follow-up information to clients through the client portal.

 

Trusted by over 185,000 nursing students worldwide, nursingbuddie.com is highly rated for therapists, speech-language pathologists, occupational therapists, and other health and wellness professionals.