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Tips for Effective SOAP Notes

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.

Contributors:Lily Hsu, Fernando Sánchez
Last Edited: 2015-12-14 09:38:16

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.

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