Writing SOAP Notes, Step-by-Step: Examples + Templates (2024)

Documentation is never the main draw of a helping profession, but progress notes are essential to great patient care. By providing a helpful template for therapists and healthcare providers, SOAP notes can reduce admin time while improving communication between all parties involved in a patient’s care.

In a few sections, we’ll give a clear overview of how therapy SOAP notes are written, along with helpful templates and software you can use to streamline the process even further. If you’re looking for a more efficient, concise way to document your telehealth sessions, this helpful guide will be of value.

How To Write Therapy SOAP Notes

Therapy SOAP notes follow a distinct structure that allows medical and mental health professionals to organize their progress notes precisely.[1]

As standardized documentation guidelines, they help practitioners assess, diagnose, and treat clients using information from their observations and interactions.

Importantly, therapy SOAP notes include vital information on a patient’s health status. This information can be shared with other stakeholders involved in their wellbeing for a more informed, collaborative approach to their care, as shown:

It’s critical to remember that digital SOAP notes must be shared securely and privately, using a HIPAA-compliant teletherapy platform. Here, we used Quenza.

The S.O.A.P Acronym

SOAP is an acronym for the 4 sections, or headings, that each progress note contains:

1. Subjective: Where a client’s subjective experiences, feelings, or perspectives are recorded. This might include subjective information from a patient’s guardian or someone else involved in their care.
2. Objective: For a more complete overview of a client’s health or mental status, Objective information must also be recorded. This section records substantive data, such as facts and details from the therapy session.
   
3. Assessment: Practitioners use their clinical reasoning to record information here about a patient’s diagnosis or health status. A detailed Assessment section should integrate “subjective” and “objective” data in a professional interpretation of all the evidence thus far, and
4. Plan: Where future actions are outlined. This section relates to a patient’s treatment plan and any amendments that might be made to it.

A well-completed SOAP note is a useful reference point within a patient’s health record. Like BIRP notes, the SOAP format itself is a useful checklist for clinicians while documenting a patient’s therapeutic progress.[REFERENCE ITEM=”Sando, K. R., Skoy, E., Bradley, C., Frenzel, J., Kirwin, J., & Urteaga, E. (2017). Assessment of SOAP note evaluation tools in colleges and schools of pharmacy. Currents in Pharmacy Teaching and Learning, 9(4), 576.”]

In the next section, you’ll find an even more in-depth template for SOAP notes that can be used in a wide range of therapeutic sectors.

Therapy SOAP notes include vital information on a client’s health status; this can be shared with other stakeholders for more informed, collaborative patient care.

3 Helpful Templates and Formats

With a solid grasp of the SOAP acronym, you as a practitioner can improve the informative power of your Progress Notes, as well as the speed with which you write them.

This generally translates into more one-on-one patient time, reduced misunderstandings, and improved health outcomes overall – so the table below should be useful.

SOAP Notes: A Step-By-Step Guide

Podder and colleagues give a great overview of the different subsections that a SOAP progress note can include. Based on their extensive article, we’ve created the following example that you can use as guidance in your work.[1]

Occupational Therapy SOAP Notes

In Occupational Therapy, a SOAP Progress Note might include the patient’s injuries and their severity, home exercises, and their effectiveness.

Based on observations and interaction with their client, an OT professional might adjust their treatment program accordingly.[2]

Laid out in the S, O, A, P format on therapy notes software, they might look like this:

Digital SOAP note tools like Quenza, which we’ve used here, will automatically create PDF copies for download, sharing, or HIPAA-compliant storage in a centralized place.

Because SOAP notes are best created while a session is still fresh in their minds, therapists might look for mobile-compatible software. This way, notes can be made on the spot from a tablet or smartphone.

Recommended: How to write Occupational Therapy SOAP Notes (+3 Examples)

Applied Behavior Analysis SOAP Notes

SOAP notes also play a valuable role in Applied Behavior Analysis, by allowing professionals to organize sessions better and communicate with a client’s other medical professionals. Legally, they may also accompany insurance claims to evidence the service being provided.[3]

It is important to remember that ABA SOAP notes, as psychotherapeutic documents, must be stored privately. They may form part of a client’s overall medical file other therapy notes.

These illustrative Occupational Therapy SOAP Notes and ABA SOAP Notes also exemplify how versatile SOAP notes can be.[4]

It’s why the framework is a commonly used standard in sectors such as Physical Therapy, Nursing, Rehabilitation, Speech Therapy, and more.

5 Examples of Effective Note-Taking

Many therapy software systems help to speed up the documentation of progress notes through in-built templates and diagnostic codes. At the end of the day, however, clinically valuable notes require careful thought and judgment when it comes to their content.

Effective notes are generally:[5]

1. Written immediately following a therapy session. This way, a practitioner’s in-session time is spent focused on patient engagement and care; writing notes immediately after helps minimize common mistakes such as forgetting details or recall bias.
2. Professional. An important part of patient Electronic Health Records, SOAP notes should be legible and make use of professional jargon to serve as a common frame of reference. They should be written in the present tense.
3. Concise and specific. Overly wordy progress notes unnecessarily complicate the decision-making process for other practitioners involved in a patient’s care. Brief, but pertinent information helps other providers reach conclusions more efficiently.
4. Unbiased: In the Subjective section, particularly, there is little need for practitioners to use weighty statements, overly positive, negative, or otherwise judgmental language. SOAP notes are frequently used both as legal documents and in insurance claims.
5. Utilize appropriate details, such as direct quotes: For a more comprehensive document that includes all the salient facts of an encounter.

An effective SOAP note is a useful reference point in a patient’s health record, helping improve patient satisfaction and quality of care.

3 Smart Software Solutions

In this section, we’ve reviewed three of the toppractice management software systems offering helpful SOAP note functions.

These include SOAP note templates, discipline-specific codes, and treatment planning features that integrate with therapy progress notes.

Software	Details
	MyClientsPlus is a mental health practice management solution that runs on the web, Android, and Apple platforms.With a loyal user base and many e-therapy features for telehealth, MCP comes with SOAP note templates that can be easily shared in multi-provider organizations.While it doesn’t offer robust treatment planning features, MyClientsPlus does include sector-specific templates and native support for telehealth sessions.
Name	MyClientsPlus
Price	$24.95+ monthly
Good For	Mental Health Coaches, Psychologists, e-Counselors, Therapists, Customer Relationship Management
More info	MyClientsPlus

Software	Details
	e-Counselors, physical therapists, speech therapists, and other practitioners creating SOAP notes will likely find value in ClinicSource SOAP templates.The software allows quick progress notes to be created, and these can then be centralized with a client’s records, alongside their billing history and summaries from each visit.Other features of this therapy notes software include Treatment Progress templates, Patient Evaluation templates, and features for building Care or Treatment Plans.
Name	ClinicSource
Price	$59+ monthly
Good For	Mental Health Coaches, Psychologists, e-Counselors, Therapists
More info	ClinicSource

Software	Details
	Power Diary has a sizable library of mental health forms that counselors, psychologists, and therapists can use to create treatment plans.SOAP and other session notes can be imported, exported, cloned, or shared to reduce admin time and centralize client records into one handy profile.Despite lacking some of the more robust mental health capabilities, such as e-prescribing, it has a low price tag and is easy for first-time clinic software users to navigate.
Name	Power Diary
Price	$5+ monthly
Good For	Speech Therapists, Psychologists, e-Counselors, Physical Therapists, Occupational Therapists, Mental Health Coaches
More info	Power Diary

Importance of Accurate and Detailed SOAP Notes

Accurate and detailed SOAP notes are crucial in ensuring effective patient care. They serve as a comprehensive record that provides continuity and clarity in treatment. Detailed notes help in tracking patient progress, identifying patterns, and making informed decisions about future care plans. They also facilitate clear communication among healthcare providers, reducing the risk of errors and misinterpretations.

Moreover, thorough SOAP notes are essential for legal documentation and compliance. They provide a clear, chronological record of patient interactions and clinical decisions, which can be invaluable in case of audits or legal inquiries. Inaccurate or incomplete notes can lead to misunderstandings, compromised patient care, and potential legal repercussions.

Additionally, precise documentation supports better patient outcomes. When healthcare providers have access to accurate and complete information, they can make more effective treatment decisions. This leads to improved patient satisfaction, as patients receive consistent and well-coordinated care. Accurate notes also contribute to research and quality improvement initiatives by providing reliable data for analysis.

Tips for Enhancing SOAP Note Quality

Improving the quality of your SOAP notes can significantly impact patient care and clinical efficiency. Here are some practical tips for enhancing your note-taking:

1. Be Clear and Concise: While it’s important to be thorough, avoid unnecessary details that don’t contribute to the patient’s care. Focus on relevant information that supports clinical decision-making.
2. Use Standardized Language and Abbreviations: Consistency in terminology and abbreviations helps ensure that all healthcare providers understand the notes. Avoid using uncommon abbreviations that might cause confusion.
3. Incorporate Patient Quotes: Including direct quotes from patients can provide valuable context and insight into their condition and concerns. This practice helps capture the patient’s perspective and can aid in more personalized care.
4. Regularly Review and Update Notes: Make it a habit to review and update notes regularly to ensure they remain accurate and relevant. This is particularly important for patients with chronic conditions or those undergoing long-term treatment.

By implementing these tips, healthcare providers can create more effective and reliable SOAP notes, ultimately enhancing patient care and clinical outcomes.

Ensuring SOAP Notes are Client-Centered

Client-centered SOAP notes prioritize the unique needs and experiences of the patient, enhancing therapeutic outcomes. Therapists can create a more tailored and effective treatment plan by focusing on individual goals, preferences, and feedback. This approach improves client satisfaction and fosters a collaborative therapeutic relationship, promoting active participation and commitment to the treatment process.

Incorporating Client Feedback: Gathering regular client feedback can provide invaluable insights into their experiences and progress. This can be done through direct questions during sessions or via follow-up questionnaires. By documenting this feedback in the Subjective section, therapists can adjust their strategies to better meet the client’s needs, ensuring that the therapy remains relevant and impactful.

Personalizing Treatment Plans: Each client’s treatment plan should reflect their personal goals and challenges. The Plan section of SOAP notes outlines specific actions tailored to the client’s circumstances. For example, if a client struggles with anxiety in social situations, the plan might include exposure therapy techniques or social skills training designed specifically for their context and preferences.

Building a Collaborative Relationship: A collaborative approach involves the client in decision-making, enhancing their sense of agency and investment in therapy. During the Assessment phase, discuss the client’s perspective on their progress and any concerns they might have. This helps create a more accurate assessment and empowers the client, fostering a more cooperative and effective therapeutic environment.

Tracking Individual Progress: Regularly reviewing and updating SOAP notes ensures that the therapy remains dynamic and responsive to the client’s evolving needs. Documenting specific achievements and challenges in the Objective section helps monitor progress over time, allowing for timely adjustments to the treatment plan. This continual adaptation is crucial for maintaining the therapy’s relevance and effectiveness.

Leveraging Technology for Efficient SOAP Note Management

With the advent of digital tools, managing SOAP notes has become more efficient and secure. Utilizing specialized software can significantly reduce the administrative burden, allowing therapists to focus more on patient care. These technologies offer features such as templates, automatic data entry, and secure storage, which streamline the documentation process and enhance data accuracy.

Digital Templates and Auto-fill Features: Many therapy software solutions provide customizable templates that simplify the process of writing SOAP notes. These templates ensure that all necessary information is captured systematically. Auto-fill features can further expedite note-taking by automatically inserting recurring details, such as client demographics and session dates, thus saving time and reducing the risk of errors.

Secure Storage and Compliance: Ensuring the confidentiality and security of client information is paramount. Digital platforms that comply with HIPAA and other relevant regulations offer encrypted storage solutions, protecting sensitive data from unauthorized access. This secure environment safeguards patient privacy and facilitates easy retrieval and sharing of notes when needed for collaborative care.

Integration with Practice Management Systems: Integrating SOAP note software with broader practice management systems can enhance overall efficiency. Such integration allows for seamless coordination between scheduling, billing, and documentation. For instance, notes from therapy sessions can be directly linked to billing codes, simplifying the administrative workflow and reducing the likelihood of discrepancies.

Real-time Data Access and Updates: Mobile-compatible software lets therapists update SOAP notes in real-time, even during sessions. This immediate documentation ensures that details are accurately recorded while they are still fresh in the therapist’s mind. Moreover, having access to notes on the go allows therapists to review patient history and progress at any time, facilitating more informed and responsive care.

Final Thoughts

With clear, consistent information on a patient’s health status and progress, therapists, psychiatrists, and counselors are much better equipped to manage their well-being. And while note-taking may not be glamorous, harnessing the right software can significantly reduce the time you spend on this vital part of healthcare.

SOAP notes play a pivotal role in streamlined, effective healthcare, and are a daily part of life for many practitioners. If you’ve tried and enjoyed using any particular templates, forms, or therapy notes solutions, let us know in a comment.

We hope this article has helped you streamline your note-taking. To put these tips into practice, don’t forget to try Quenza’s SOAP Notes tools for just $1 a month.

If you want to enhance the wellbeing of your clients more effectively, Quenza will give you everything you need to streamline your therapy notes, so you can focus on delivering the wellness results that matter.

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