SOAP Notes Explained – Everything You Need to Know about SOAP Notes
Best Guide on What You Need to Know: SOAP Note Examples, Meaning, Tips & More
When a therapist, mental health care provider, nurse, or other health care professional meets with a patient, the session is typically documented. These notes become a very important part of the patient’s health record.
What happened during the session? How is the individual progressing in their treatment? What is the professional’s assessment and plan for their continued care? This is some of the information that is documented in these meeting/session notes.
How those notes are formatted is where SOAP notes come in. The SOAP documentation method is one of the most popular ways to format these session notes. SOAP clinical notes are used throughout the medical and mental health professions and social work community.
Assessment in SOAP Note
Writing SOAP Notes keeps documentation consistent and has other benefits, such as providing a streamlined way to write down important information about each patient meeting.
Learning SOAP note taking can make the job of documenting progress notes and client interactions easier. Using the four parts of a SOAP note can also improve the accuracy and completeness of these notes.
In this Social Work Portal article, we’ll review the importance of SOAP notes and go through SOAP method case notes in detail. We’ll also go through several SOAP format examples.
Also…don’t miss our free SOAP case notes example and template that you can download from our All-in-One Client & Case Management Software.
Table of Contents: SOAP Notes Social Work
Keep on scrolling down this page to read each section or click any link below to go directly to that section.
- SOAP Notes Meaning
- What Is the Benefit of Using the SOAP Note Format?
- S in SOAP Note Form (Subjective)
- O in Soap Note Acronym (Objective)
- A in Soap Note Structure (Assessment)
- P in Soap Format (Plan)
- Tips for Writing Good SOAP Therapy Notes
- SOAP Notes Examples for Social Workers
- Downloads: SOAP Note Assessment Example & Free SOAP Format Word Template
- Conclusion | SOAP Note Format & How to Write a SOAP Assessment
- FAQ | SOAP Case Notes
SOAP Notes Meaning
SOAP in medical terms was introduced by Lawrence Weed, MD, almost half a century ago. The SOAP form of taking notes came from the problem-oriented medical record (POMR).
How do you define SOAP notes?
Here is what each of the letters in SOAP note stands for:
These four terms in a SOAP note plan example represent different note sections. You can think of the parts of a SOAP note as headers. The social worker or therapist uses these headers to organize the session notes in a consistent manner.
Shortly, we’ll go through each area of SOAP case notes social work professionals and medical practitioners use and explain the types of details entered into each SOAP acronym.
Do you have any questions or feedback about this article on therapy SOAP note example, SOAP notes physiotherapy, and an assessment in SOAP? If so, click here to contact the Social Work Portal Team.
What Is the Benefit of Using the SOAP Note Format?
Why is the subjective objective assessment plan format in SOAP notes so popular? Besides being around for nearly 50 years, the SOAP note example is a simple, yet effective method for organizing patient progress notes.
Here are some of the benefits of adopting a SOAP note plan for your patient documentation:
- Improves note-taking efficiency
- Helps providers formulate treatment strategies
- Ensures completeness of progress notes
- Widely used in the social work & medical communities
- Helps providers communicate information with team members
- Organizes patient session documentation
- Reduces miscommunication between healthcare professionals
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In the next sections, we will dive into each of the four sections of the SOAP model case notes format, beginning with the “s” for subjective in SOAP note format case notes.
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S in SOAP Note Form (Subjective)
The first letter in the SOAP subjective objective assessment plan framework is “S” for subjective. Subjective in SOAP note methodology is the area of your notes where you include the patient’s subjective description of their situation.
This could be how they are feeling, or what they think of their environment, progress, or situation. You might want to start a subjective SOAP note example with “The client feels…” or “The client stated…”
The SOAP note guide for this subjective area is to include the patient’s perspective. You may also include the perspective of the patient’s family if you met with them during the session.
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Do you have a de-identified SOAP progress note example or mental health SOAP note example that you feel would be helpful to share with other social workers? If so, click here to contact the Social Work Portal Team.
O in Soap Note Acronym (Objective)
The next acronym in the SOAP writing method stands for objective. This section is for the social worker, medical, or mental health professional to enter their objective observations of the patient and the patient’s situation.
The objective in SOAP note format should contain measurable and observable details. Think of this section as one to enter facts and data, not opinions or feelings.
A SOAP note objective example would be the number of times a patient took drugs since the last session, or it might be another preset measure of progress toward therapy goals.
Another SOAP objective example would be observations about the patient. Such as, “The individual had a large bruise on their left cheek that was not there at our last session two weeks ago.”
A in Soap Note Structure (Assessment)
The assessment section of SOAP note templates is the appropriate place for the mental health or medical professional to add their opinions about the client’s situation and assessment of progress during this session or meeting.
Assessment in SOAP note forms is where you will sum up what is going on in the “S” and “O” portions of the SOAP form and give your professional opinion of what that means.
A SOAP assessment example might be that the client is progressing well in dealing with self-doubt issues, but still needs to work on their anxiety issue, which seems to be getting worse.
The SOAP format social work, medical, or mental health assessment includes the professional’s clinical interpretation of the client’s current situation and/or progress in their treatment plan.
P in Soap Format (Plan)
The final section of the progress note SOAP format is for plan. This section is where you will write down your next steps in the patient’s treatment plan.
When using SOAP format case notes, the plan area should be tied into your ongoing treatment plan for the individual and may refer to past session SOAP notes.
Based on your assessment of the client’s progress, include any short-term or long-term plans that you are implementing or recommending. For example, your social work case notes SOAP plan section might state that the individual is being sent to a drug rehabilitation facility. Or it could note a reduction in sessions because the patient is progressing well in therapy.
The plan will be what your next session’s SOAP follow up note will reference when assessing progress toward goals.
Do you have any questions about the difference between soap objective example and soap note plan example? Or do you have feedback about the best mental health soap note example that has worked well for you? If so click here to contact the Social Work Portal Team.
Tips for Writing Good SOAP Therapy Notes
As you can imagine, during a patient or client session a lot of different information will be collected. This includes how the patient is feeling or dealing with the issue being addressed, what the health care professional is observing about the situation, their assessment, and what to do next.
The SOAP note format example provides a way to take all that information and create organized and meaningful case and progress notes. To get the most out of SOAP progress notes, we have some tips you can use.
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Good Soap Note Example Tips:
- Keep notes to 1-2 pages and focus on the most important information that needs to be documented.
- Keep the content unique to this session, don’t just repeat the prior session notes.
- Avoid personal judgments and the use of “good” or “bad” to describe behavior.
- Make statements that are supported by measurable or observable information.
- Notes should be easy to read. Type online SOAP notes into a form or app, or if writing SOAP notes by hand, make sure they are legible.
- Don’t use unsourced opinions.
- Describe ongoing plan progress and next steps, rather than recreating your plan in every SOAP assessment example.
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SOAP Notes Examples for Social Workers
To help you better understand SOAP note guidelines, we’ve included three SOAP note example scenarios below. These are fictitious and designed for educational purposes.
You’ll also note that the SOAP note assessment examples below are short to provide brief examples for you to get the general idea of the SOAP framework. Your SOAP progress notes will likely be a bit longer.
Pediatric SOAP Note Example
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SOAP Notes Counseling Example
Psychiatric SOAP Note Example
|Subjective:||Elaine is still feeling very depressed and isolated. She states that she occasionally “hears voices, but I can’t make out what they are telling me.” She doesn’t like the side effects of her prescribed medication but admits that it helps her symptoms.|
|Objective:||Elaine’s clothing looks unwashed, and her appearance is disheveled. She speaks in a rushed fashion.|
|Assessment:||The lack of progress is concerning. Elaine has auditory hallucinations, a key indicator of schizophrenia.|
|Plan:||Elaine’s medication is being changed to Aristada Initio at 675 mg. The next session with Elaine is in three days.|
Do you have questions about any SOAP note example that we’ve provided, like the SOAP notes counseling example? Do you need more references about SOAP in medical terms? If so, click here to contact the Social Work Portal Team.
Downloads: SOAP Note Assessment Example & Free SOAP Format Word Template
Are you looking to use the SOAP subjective objective assessment plan format for your client or patient progress notes? We have two printable SOAP notes downloads that you can leverage to enable your work.
The first is a therapy SOAP note example PDF that you can download, print out, and reference to help you better understand SOAP notes meaning when writing your own.
The second is a blank SOAP assessment template for you to use. It includes the four sections of the SOAP format example: Subjective, Objective, Assessment, and Plan.
Do you have any feedback about this article or need additional soap note objective examples? If so, click here to contact the Social Work Portal Team.
Conclusion | SOAP Note Format & How to Write a SOAP Assessment
The SOAP acronym and SOAP note assessment example has proven to be an efficient way of documenting patient and client case notes. It provides a repeatable and consistent method of relaying complex information.
Anyone in the social work or medical field should study at least one SOAP format example to familiarize themselves with this popular note-taking framework.
Whether you use SOAP notes physiotherapy templates, social work SOAP notes, or SOAP in medical terms, this flexible format should be a key tool in your patient documentation toolbox.
For questions about the main objective in soap note taking or feedback on the best soap documentation method, click here to contact the Social Work Portal Team.
Is there something else you’d like to know about soap clinical notes, soap model case notes, or soap note guidelines? If so click here to contact the Social Work Portal Team.
FAQ | SOAP Case Notes
What are the 4 parts of SOAP?
SOAP note stands for four key sections for organizing patient or client session notes. The four parts of SOAP are Subjective, Objective, Assessment, Plan.
How do you make SOAP notes?
Writing SOAP notes means following the SOAP format, beginning with the S in SOAP note, which stands for Subjective. In this area, the subjective feelings and opinions of the patient are noted.
Next is the O in SOAP notes, which is for Objective. This is where the health care professional will include their objective observations of the patient.
The A in SOAP note is for Assessment. This is the section where the health care professional will describe their assessment of the patient and their situation.
The P in SOAP stands for Plan. The next steps for the patient to take are included in this part of a SOAP note.
What is the benefit of using SOAP notes?
Here are some of the benefits of adopting a SOAP note plan for your patient documentation:
•Improves note-taking efficiency
•Helps providers formulate treatment strategies
•Ensures completeness of progress notes
•Widely used in the social work & medical communities
•Helps providers communicate information with team members
•Organizes patient session documentation
•Reduces miscommunication between healthcare professionals
How do you take good SOAP notes?
Good Soap Note Tips:
•Keep notes to 1-2 pages and focus on the most important information.
•Keep the content unique to this session.
•Avoid personal judgments and the use of “good” or “bad.”
•Make statements that are supported by measurable or observable information.
•Notes should be easy to read.
•Reference your ongoing plan progress and add to it.
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