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Contributors:Lily Hsu, Fernando Sánchez.
Summary:

This resource provides information on SOAP Notes, which are a clinical documentation format used in a range of healthcare fields. The resource discusses the audience and purpose of SOAP notes, suggested content for each section, and examples of appropriate and inappropriate language.

SOAP Notes

What is a SOAP note?

A SOAP note is a form of written documentation many healthcare professions use to record a patient or client interaction. Because SOAP notes are employed by a broad range of fields with different patient/client care objectives, their ideal format can differ substantially between fields, workplaces, and even within departments. However, all SOAP notes should include Subjective, Objective, Assessment, and Plan sections, hence the acronym SOAP. A SOAP note should convey information from a session that the writer feels is relevant for other healthcare professionals to provide appropriate treatment. The audience of SOAP notes generally consists of other healthcare providers both within the writer’s own field as well in related fields but can also include readers such as those associated with insurance companies and litigation. A good SOAP note should result in improved quality of patient care by helping healthcare professionals better document and therefore recall and apply details about a specific case.  

How long is a SOAP note and how do I style one?

The length and style of a SOAP note will vary depending on one’s field, individual workplace, and job requirements. SOAP notes can be written in full sentence paragraph form or as an organized list of sentences fragments. Note the difference in style and format in the following two examples. The first come from within a hospital context. The second is an example from a mental health counseling setting.

Example #1

11/1/97

S – Nauseated, fatigued

O – Less jaundiced

       Liver less tender

       Taking adequate calories and fluid

       Ultrasound liver/billary tract: normal

A – Seems to be improving

       No obstruction

P – Check liver tests tomorrow

      Phone laboratory for hepatitis markers

(from Heifferon, 2005, p. 103)

Example #2

7/7/01 2 p.m. (S) Reports counseling is not helping him get his family back. Insists the use of violence has been needed to “straighten out” family members. Reports history of domestic violence. Recent history: States he met and verbally fought with his wife yesterday regarding the privileges of oldest child. Personal history: childhood physical and mental abuse resulting in foster care placement, ages 11-18. (O) Generally agitated throughout the session. Toward the end of the session stood up, with clenched fists and jaw, angrily stated that counseling is “same old B.S.!” Rushed out of office. (A) Physical Abuse of Adult [V61.1 DSM code] and Child(ren) [V61.21]. Clinical impressions: rule out Intermittent Explosive Disorder given bouts of uncontrolled rage with non-specific emotional trigger. (P) Rescheduled for 7/14/01 @ 2 p.m.; Continue cognitive therapy. Refer to Men’s Alternatives to Violence Group. Next session, introduce use of “time-outs.” S. Cameron, Ph.D., LPCC (signature).

(from Cameron & turtle-song, 2002, p. 80).

Key Points

These examples are not the only two ways to write a SOAP note. Rather, they showcase differences in approaches for SOAP note styles. As mentioned above, different fields and even different clinics will have varied preferences and practices for writing these clinical documents.  

Despite this variation, it is important to keep in mind that a SOAP note should be sufficiently detailed so that an outside healthcare provider with no previous interaction with the patient/client can obtain all the necessary information from the session or incident documented to appropriately provide care for the patient/client. Conversely, also keep in mind that efficiency and time management are important in the healthcare professions. To save both the writer and reader time, avoid overly wordy phrasing and unnecessary detail. It is perfectly acceptable and often encouraged in many settings to use abbreviations when writing SOAP notes. In some settings, especially those that use electronic healthcare records, the writer will be constrained to a predetermined number of characters that can be entered.

Abbreviations

Some commonly used abbreviations for SOAP notes are:

b/c- because

CC- chief complaint

c/o- complained of

cl- client

d/t- due to

Dx- diagnostic test

Ed- education

e.g.- exempli gratia, use when giving an example

HPI- history of present illness

i.e.- id est, use when giving alternative explanation or wording

min, mod, max- minimum, moderate, maximum

Mx- monitoring test

Rx- treatments

sx- symptoms

w/, w/o- with, without 

References

Cameron, Susan & turtle-song, imani. (2002). Learning to write case notes using the SOAP format. Journal of Counseling & Development, 80, 286-292.

Heifferon, Barbara A. (2005). Writing in the health professions. New York: Pearson/Longman.

Contributors:Lily Hsu, Fernando Sánchez.
Summary:

This resource provides information on SOAP Notes, which are a clinical documentation format used in a range of healthcare fields. The resource discusses the audience and purpose of SOAP notes, suggested content for each section, and examples of appropriate and inappropriate language.

SOAP Note Sections: S, O, A, & P

This section explains the four major sections of a SOAP note, Subjective, Objective, Assessment, and Plan.

Subjective

The subjective section should describe the practitioner’s impressions of client/patient and information reported about or by the client/patient.

Sample Language:

“Client appropriately interacted with clinician throughout the session.”

“Clinician informed unit nurse of client’s c/o pain in lower back.”

The subjective section can also be an area where the client’s own voice comes through. Depending on the field in which you are writing notes, you may want to include paraphrased information on what the client said, using quotes for pertinent language,  client’s stated progress and link to previous notes’ goals, or what the client reported to be relevant for this session.

Sample language:

“Cl mentioned that her brother had called her an ‘egomaniac’ and ‘stupid’ this week. Client reported that she’d ‘had enough’ of her brother’s taunts and that she couldn’t understand why he had to treat her so poorly.”

Note that the above example only includes key words and phrases from the client, rather than extended passages of client language.

Possible details to include: level of attention, level of engagement, family member’s or other healthcare provider’s report to practitioner regarding the client/patient, client quotes, client’s report of anything practitioner feels is significant 

Objective

The objective section should include all pertinent measurable information taken during the interaction.  Think of this section as consisting of information that anyone observing the interaction with the patient or client could agree to have happened.

Sample Language:

“Client obtained 70% accuracy on short term goal #1.”

"Near the end of the session, the client began to cry when she discussed not being able to find a new job after 4 months of searching."

Possible details to include: measurements taken, test results, data taken on therapy goals, quantifiable observations  

Assessment

The assessment section should include the practitioner’s analysis of the session. If the practitioner has had previous interactions with the client/patient, the section can include an analysis of the interaction being documented compared to previous interactions.

As with all sections of SOAP notes, the Assessment section should be written very carefully. Although this is an area for the clinician to include his/her professional impressions, no statements should be written that cannot be verified with evidence.  It is important to keep in mind that there are numerous individuals who will have access to these notes, so the assessment of the patient or client should be based on assessments or observed behavior.

Sample Language:

“Performance on problem solving tasks is a relative strength.”

“Client states that he has withdrawn from social activities with peers. He has expressed having reduced energy, diminished sleep (typically only getting about 4 hours a night), and pessimistic thoughts. Client may be experiencing mild depression. No other symptoms were reported or observed.”

Possible details to include: Treatment efficacy or inefficacy, analysis of a specific detail that was unusual or unexpected, methods that proved particularly motivating or successful for the patient/client and those that did not, information from the subjective and objective section to help strengthen clinical hypotheses   

Plan

The plan section should outline the course of treatment for a future or future interactions.

Sample Language:

“Continue with POC.” (plan of care) 

“Prepare bill and send to client’s spouse.”

“Modify short term goal 2B to reflect client’s present level of ability.”

Possible details to include: goals and objectives for the clinician between this session and the next, goals and objectives for the patient or client between this session and the next, changes in treatment, changes in therapy goals, administrative business, referrals, topics to be discussed, interventions or treatments to be implemented 

Contributors:Lily Hsu, Fernando Sánchez.
Summary:

This resource provides information on SOAP Notes, which are a clinical documentation format used in a range of healthcare fields. The resource discusses the audience and purpose of SOAP notes, suggested content for each section, and examples of appropriate and inappropriate language.

Tips for Effective SOAP Notes

Tips for Effective SOAP Notes

Find the appropriate time to write SOAP notes.

Avoid: Writing SOAP Notes while you are in the session with a patient or client. You should take personal notes for yourself that you can use to help you write SOAP notes.

Avoid: Waiting too long after your session with a client or a patient has ended.

Maintain a professional voice.

Avoid: “The client had a blast during the group therapy session.”

“Had a blast” is informal and not descriptive.

Use instead: “The client smiled and laughed during the group therapy session.”

This statement specifically describes the actions of the client and maintains a formal voice.

Avoid overly wordy phrasing.

Avoid: “Careful consideration and thought have lead this clinician to conclude that the client responds very positively to physical cues.”  

This statement is overly wordy and could be simplified to state the main idea in a quicker and more precise manner.

Use instead: “The client shows greater success with activates involving physical cueing.”  

This statement quickly draws a conclusion that might be helpful for a future practitioner. 

Avoid biased overly positive or negative phrasing.

Avoid: “The client could not even say his own name.”

This statement is judgmental and makes an assumption about the client’s ability without specific evidence to substantiate it.

Use instead: “The client did not verbalize his name after being prompted twice by the clinician, ‘Tell me your name.’”  

This statement gives specific information regarding the client’s behavior under specific circumstances without being judgmental.

Be specific and concise.

Avoid: “The client was able to write her name.”

This statement is vague, and it is unnecessary to write “was able to.”  

Use instead: “Given a pen, paper, and verbal instructions, the client wrote her name legibly.”

This statement gives specific details regarding the circumstances of the observation and is not overly wordy.

Avoid overly subjective statement without evidence.

Avoid: “Client was very frustrated”

Words like “very” and “a lot” do not help the reader understand behaviors of the client.

Use instead: “Client grimaced and sighed repeatedly during the latter half of the therapy session”  

This statement gives the reader a clear description of the client’s behaviors without making assumptions about the client’s internal state that lack specific support. 

Avoid pronoun confusion.

Avoid: “The clinician instructed the client to state her name.”

It is unclear whose name the client was asked to say.

Use instead: “The clinician instructed the client to state the client’s first name.“

A commonly used term in some fields that can help to avoid confusion is “this clinician.”

Avoid: “Client stated that his father was in town. He reported that he feels that he frequently

ignores what he says whenever they are together.”

Who is ignoring whom?

Use instead: “Client stated that his father was in town. Client reported that he feels that his

father frequently ignores what the client says whenever they are together.”

Be accurate but nonjudgmental. 

While other healthcare professionals are the primary audience of SOAP notes, be sure that the SOAP note is written so that it would not be construed as offensive were a family member to read it.

Avoid: “The client’s mother, obviously mistaken, claimed that Susie said her first word at three months of age.”

The wording “obviously mistaken” is overly judgmental and does not add any important information to the SOAP note.

Use instead: “The client’s mother reported that Susie said her first word at three months of age.”

This statement is accurate and nonjudgmental. A healthcare professional familiar with typical language development would recognize that such an event is implausible.

Contributors:Lily Hsu, Fernando Sánchez.
Summary:

This resource provides information on SOAP Notes, which are a clinical documentation format used in a range of healthcare fields. The resource discusses the audience and purpose of SOAP notes, suggested content for each section, and examples of appropriate and inappropriate language.

Additional Resources

Baird, Brian N. (2014). The internship, practicum, and field placement handbook. 7th Ed. New York: Routledge.

Cameron, Susan & turtle-song, imani. (2002). Learning to write case notes using the SOAP format. Journal of Counseling & Development, 80, 286-292.

Heifferon, Barbara A. (2005). Writing in the health professions. New York: Pearson/Longman.

Kettenbach, Ginge. (2009). Writing patient and client reports: Ensuring accuracy in documentation. 4thEd. F.A. Davic Co.

Moline, Mary E., & Borcherding, Sherry. (2013). The OTA’s guide to documentation: Writing SOAP notes. 3rd Ed. Thornfield, NJ: Slack Inc.

Moline, Mary E., Williams, George T., & Austin, Kenneth M. (1998). Documenting psychotherapy: Essentials for mental health practitioners. Thousand Oaks, CA: Sage.

Sullivan, Debra D. (2011). Guide to clinical documentation. 2nd Ed. F.A. Davis Company.