A brief overview of SOAP notes
SOAP notes are a widely used and accepted format by healthcare professionals to capture client information in a way that is easy to understand. Using a SOAP note format, clinicians can ensure they extract valuable information from patients in both a subjective and objective manner. Healthcare professionals can then assess the patient for a viable and effective treatment plan to alleviate their clinical diagnosis using the information gathered.
Using this universal format to store patient data, clinicians can ensure a sense of patient compliance in healthcare, with information represented truthfully. Subjective observations allow clinical patients to present their firsthand experience to be treated efficiently and in a manner that directly addresses their healthcare issues.
Explaining SOAP note with an example
SOAP notes follow a process, but it doesn’t have to be complicated.
What do you write in a SOAP note?
A SOAP note example structure includes four main components:
- Subjective section - focusing on client’s own experience and perception of symptoms
- Objective section - refers to objective medical information that can be quantified, calculated, or verified, such as vital signs and evaluations
- Assessment section - a summary of the evaluation, used as the basis to make a plan
- Plan section - used to formulate a treatment plan for the client based on previous observations, which addresses their described and perceived health care issues
It can be helpful to visualize this plan in explaining SOAP notes with an example.
Subjective:
The subjective section aims to capture patient information from their experience and focus on their preferences, needs, and symptoms. This may include using direct quotes, such as “I feel restless all the time,” with it quoted verbatim as not to misconstrue and properly inform other medical health professionals who use the data. This section allows clinicians to document firsthand what the patient feels and enables commentary from family members, supporters, or other contacts. This way, professionals who review this information can have a clearer picture, with valuable insight into the authentic experience of the client.
It is important not to paraphrase, provide irrelevant information, or make statements about the client without primary evidence. The subjective experience relies on the client guiding this section, with their experience of symptoms and mental health brought to light.
A SOAP medical example for subjectivity should involve quotes as demonstrated:
John reports low mood throughout the day, in conjunction with a loss of interest and motivation. “I feel sad. I used to enjoy my morning runs, but I find it so hard to motivate myself to go. I don’t care, to be honest. That feeling never goes away throughout the day either.”
Objective:
In the objective section, the goal is to include factual observations and quantifiable measurements, assessments, tests, and vital signs. This may also include various types of medical information, x-ray results, or exams. Note that it is essential to distinguish between describing and listing facts to noting observations about the symptoms shown in the patient. For instance, symptoms are the patient’s experience of a condition, whereas signs used for the objective section are objective observations of symptoms. SOAP charting examples may include blood pressure, heart rate, hypertension, body shakes, and shallow breathing for someone who has anxiety. What is observed here may or may not contradict or complement what is demonstrated in the subjective observations. Because it is an objective section, this means your SOAP notes should refrain from general statements without supporting evidence. There should also be no opinion or personal judgments, as that may interfere with the observations recorded. It is also best to use professional language that minimizes the risk of misinterpretation, as this needs to be communicated clearly to other healthcare professionals.
An example of the objective section:
John has slow communication and slow motor movements. His speech suffers from a flat affect with little expression or variation in his voice, which is mirrored in his facial movements.
Assessment:
SOAP format of assessment enables clinical healthcare professionals to assess the subjective and objective observations recorded to work towards the client’s progress. It serves as a commentary on the client’s current state and synthesizes the prior evidence to provide a more precise representation of a potential definition of a diagnosis. The assessment allows for a systematic analysis of the main issue, any underlying or related issues and enables the practitioner to have a ‘bigger picture’ perception of what is going on. For psychology issues that are more frequent and distinct, this assessment is conducted more linearly, whereas, with disorders that have high comorbidity, this process may take longer.
Essentially, the assessment is working towards a treatment plan, evaluating how the client is currently doing with their available resources. It is important to note their diagnosis, their progress, and any changes in medication or treatment. This should all be presented professionally and without repetition from previous sections.
An example of this section includes:
John has Major Depressive Disorder (MDD) and is currently seeking CBT as treatment. He came in today with the intensification of previous symptoms, as shown by his disengagement from activities he used to find enjoyable. This indicates the presence of MDD, and more intensely than last week. He does not seem to be responding to therapy and would benefit from further treatment.
Plan:
The plan section is the final section that compiles the assessment and analysis of observations to define the next course of action for the patient. This helps determine a direction for the client and identifies the clear next step for them to undertake to work towards their healthcare goal. This may mean continuing or amending the current treatment plan or establishing a new one. A new treatment plan could mean changes in activity, medication, or goals. It would prove beneficial to include the treatment currently provided, with your rationale behind administering it, as well as the client’s immediate response to existing treatment. Because a plan incorporates direction and specific steps, it is helpful to include when their next session is, what they will be working on in the meantime, and reevaluation and establishment of goals. While it is beneficial for you as a clinician to have a direction for your consultation, it is more important for the client to understand their next steps to maintain productivity towards their end goal.
A SOAP report example of the plan section could be:
John is undergoing CBT to alleviate symptoms of MDD. Because he is not responding well, John would benefit from seeing a psychiatrist to be prescribed SSRIs, if appropriate. As usual, John is to continue seeing me in therapy next week, regardless of his choice to be treated via medication. I have discussed with John some new behavioral techniques to reduce some of his prominent symptoms presented today potentially.
Benefits of SOAP notes
SOAP notes provide immense benefits for professional health clinicians within the healthcare business space. Many online healthcare platforms, such as Carepatron, offer an integrated workplace to store SOAP note documentation. In addition to this, many platforms like Carepatron also offer SOAP templates to work from to make this process easier. This is highly beneficial considering that SOAP notes are:
Easy to understand - Because of the SOAP formatting, they are clear to read by all healthcare professionals and are primarily used in healthcare facilities
Easy to interpret - Because of their professional approach, SOAP notes clearly outline the process from observation to the treatment plan
Provide both subjective and objective perspectives - Allow for the client voice of their experience, as well as the scientific method to confirm what is seen
Allows for compliance - As a documentation method, SOAP notes enable medical professionals to be held accountable for their healthcare practices, which avoids and reduces the misinterpretation and misconstruing of information.
SOAP notes are a widely accepted and used documentation method for clinical practices, which provide immeasurable value. With the right healthcare platforms, such as Carepatron, this process can be made even easier to incorporate into your routine.
One SOAP note example to rule them all: Try Carepatron for free today!
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