SOAP Note Examples

This guide will help you master the art of SOAP note writing, providing you with tools to create proficient and client-centric documentation.

We’ll start with an introduction to the SOAP note format. Then, we’ll discuss insights into what to include in your SOAP notes and how to format them effectively, with examples across multiple disciplines.

Understanding the SOAP Note Format

SOAP stands for Subjective, Objective, Assessment and Plan. SOAP notes are a documentation tool that helps ensure clinical notes are recorded accurately, consistently and include an appropriate treatment plan.

The SOAP format was introduced in the 1960s by Dr. Lawrence Weed, known for his work in medical record standardization. His vision was to improve the quality of client care by creating standard client documentation systems. The success of his work is evident in the broad use of SOAP notes in allied health to this day.

Key Components of a SOAP Note

SOAP notes consist of four sections: Subjective, Objective, Assessment and Plan.

Let’s explore these components in detail, along with formatting tips to help ensure your documentation is clear and concise.

Subjective: Capturing the Client’s Voice

This section covers the client’s perspective. Document the client’s history, symptoms and concerns exactly as they express them.

Use direct quotes when possible. Begin with the client’s stated reason for the current visit and include relevant client history and symptoms.

Possible subheadings to guide the format of this section are listed below:

• History of Present Illness (HPI): This may include stated symptoms, a chronological history of the client’s medical or mental health complaints, and information obtained from other sources (identify the source if it’s not the client).
• History: This might include medical history, family history and/or social history.
• Review of symptoms: This involves a set of questions designed to help the client identify symptoms they might previously have overlooked.
• Current medications or allergies: Include this information under the Subjective or Objective sections, if applicable to your practice. Record all current medications and allergies reported by the client. Include the medication name, dose, route, and frequency of intake.

Objective: The Facts & Figures

This part must include tangible, measurable data. Include vital signs, affect, physical state, test results and other observable data.

Use clear, precise language. Present data in a logical order, and ensure all measurements and findings are recent, objective and accurate.

Observations may include:

• Vital signs
• Physical exam findings
• Laboratory data
• Imaging results
• Mood and affect
• Posture
• Other diagnostic data
• Recognition and review of the documentation of other clinicians.

Bear in mind

Symptoms are what the client reports (that’s why they’re under the Subjective section of SOAP notes), whereas the Objective section should cover what you observe.

Assessment: Making Sense of the Information

Here, you’ll collate your clinical assessments and diagnoses based on information recorded in the Subjective and Objective sections.

Arrange your thoughts clearly. Start with the primary diagnosis, followed by secondary ones (a differential diagnosis) if applicable. Briefly justify your diagnoses with supporting data.

Here’s a formatting example:

• Problem: Here, you’ll list the “problems” (or diagnoses), based on your assessment of the above information. Best practice is to list these in order of importance or urgency.
• Differential Diagnosis: List all possible diagnoses, even the ones that are less probable. Under this subheading, you’ll explain your decision-making process in detail and justify your thought process.

Plan: Mapping Out the Road Ahead

This section outlines the treatment plan, follow-up appointments and client education. Mention specific medications, therapies, referrals to specialists or recommended lifestyle changes.

Be specific and action-oriented. Include timelines, dosage for medications if applicable and clear instructions for follow-up.

The following may be helpful for your Plan format:

• Record your recommendations for possible further tests and reasons for recommending each test
• Further interventions needed
• Specialist referral(s)
• Client education

Remember

The key to effective and professional SOAP notes is clarity and brevity. Each section should be concise yet comprehensive, providing all needed information without unnecessary detail.

This approach ensures that your SOAP notes are useful for your practice and other healthcare professionals involved in the client’s care.

SOAP Note Examples Across Specialties

Let’s look at hypothetical SOAP note examples from different specialties.

Example 3: SOAP Note Format Example for Mental Health Practitioners

Subjective

The client expresses feeling “overwhelmed” after being promoted two months ago, as well as unexplained bouts of “dizziness and a racing heart” while at work. She reported “finding it hard to fall asleep” due to “thinking and worrying about work.”

She confirms that, on average, she sleeps less than 4 hours per night, as she prefers to work late and rise early to “get ahead” of her day. She describes herself as a “perfectionist” and often spends more time than she intended on a task. She likes to be seen as capable and productive and fears disappointing her employer and colleagues.

The client reports that she finds it hard to ask for help and talk about her feelings with others and has only sought counseling after being directed to do so by her employer.

In retrospect, she says she has always been a “worrier” and finds it difficult to cope with change, but since the promotion, the anxiety has begun to interfere with work and her personal life. Her partner has been concerned about the level of pressure she has been under at work.

Objective

The client is a 33-year-old woman, well-groomed and dressed in professional attire.

She appears fidgety and restless and speaks rapidly, demonstrating a sophisticated vocabulary. The client interrupted the session on three occasions to update her schedule as various tasks or priorities occurred to her.

The client massaged her temples repeatedly throughout the session and was constantly rubbing her thumb across the opposite hand in small circles.

The client reports poor sleep and appetite.

No reported family history of mental health conditions.

The client denies thoughts of self-harm or suicide.

Assessment

The client’s symptoms are consistent with an adjustment disorder. Although she has always been a worrier, the client reports increased anxiety since she was promoted at work two months ago. The anxiety is now impacting her work performance and relationships.

• Diagnosis: Symptoms suggestive of adjustment disorder.
• Differential diagnosis: Possible generalized anxiety disorder. Further exploration of mental health history needed.

Plan

• Immediate: Begin cognitive behavioral therapy. Discuss sleep hygiene techniques. Schedule weekly sessions.
• Follow-Up: Should the above recommendation not bring relief to the client within two months, a further exploration of differential diagnoses will be required.

Adapt as you go.

In each of the above examples, the basic SOAP structure is maintained, but the content is tailored to suit the focus of each specialty.

Whether it’s the precise physical measurements in physical therapy, the exploration of thoughts and feelings in mental health, a focus on daily living activities in occupational therapy, or the specific muscle groups in massage therapy, the SOAP format’s flexibility makes it a valuable tool in a wide range of clinical settings.

Formatting Recommendations for SOAP Notes

Creating SOAP notes that are both informative and efficient requires attention to structure, effective use of technology, and a balance between detail and conciseness.

Here are a few formatting recommendations to help you craft SOAP notes that effectively communicate client information while being easy to read and use.

Structure: Bullet Points vs. Paragraph Form

• Bullet Points: Use bullet points for clarity and quick reference. They’re ideal for listing symptoms, observations and action items, making it easier to scan the document.
• Paragraph Form: Use this for the Subjective and Assessment sections where a narrative style is needed to convey the client’s story or a comprehensive assessment.
• Combination Approach: Consider combining both forms. For example, use bullet points in the Objective section for clear data presentation and paragraph form in the Subjective section for detailed client history.

Use Templates and Electronic Health Record (EHR) Systems

• Templates: Templates provide a consistent structure for notes, ensuring you include key information. Adapt templates to fit the specific needs of your practice.
• EHR Systems: Choosing the right EHR system to record SOAP notes means that your clients’ data is stored securely, and is easy to access from anywhere with an internet connection.

Balancing Comprehensive and Concise Documentation

• Relevance is key: Focus on what’s relevant to the client’s current condition and treatment plan.
• Clarity and brevity: Strive for notes that are clear and to the point. Use simple, direct language and avoid industry jargon.
• Consistency: Maintain a consistent level of detail across all sections. This helps create a coherent picture of the client’s condition and care plan.

Remember, the primary goal of SOAP notes is effective communication.

SOAP notes should provide a clear, concise and comprehensive record that supports client care and facilitates collaboration among healthcare providers.

Benefits of Different SOAP Note Approaches

SOAP notes can be formatted using different styles, each offering unique benefits in specific clinical scenarios. These approaches can be classified as client-centered or problem-centered, both having significant impacts on client outcomes and healthcare team efficiency.

Let’s dive into a comparison of these approaches:

SOAP Note Formatting Styles & Their Clinical Benefits

• Narrative style: This style is beneficial in mental health or counseling settings where understanding the client’s story and perspective is crucial. It allows for a detailed account of the client’s experiences and feelings.
• Bulleted or checklist style: Often used in fast-paced environments like emergency rooms or urgent care, this style allows for quick information retrieval and efficient documentation.
• Hybrid style: Combining narrative and bulleted formats, this approach works well in settings like family medicine or chronic care management, where both detailed descriptions and quick data references are needed.

Client-Centered vs. Problem-Centered Approaches

• Client-centered approach: This approach focuses on the client’s overall experience, feelings and perceptions. It’s beneficial in therapeutic settings, promoting a holistic view of the client’s well-being.
• Problem-centered approach: This approach is more focused on specific medical or physical issues. It can be effective in acute care or when dealing with a specific diagnosis.

Impact on Client Outcomes & Healthcare Team Efficiency

• Client outcomes: Good SOAP note formatting, whether client-centered or problem-centered, ensures that all relevant information is captured and easily accessible. This can lead to more accurate diagnoses, tailored treatment plans and better overall client outcomes.
• Healthcare team efficiency: Efficient SOAP note formatting enables quicker information retrieval and easier communication among healthcare professionals. This can result in better coordination of care, reduced errors and more efficient use of healthcare resources.

The choice of SOAP note formatting and approach should be guided by the specific needs of the clinical setting and the nature of the client’s condition. Both client-centered and problem-centered approaches have their place in healthcare, or even a thoughtful combination of both, tailored to each client’s and situation’s individual needs.

Adapting SOAP Notes to Modern Healthcare Challenges

Healthcare is continually evolving. SOAP notes must adapt to changes, particularly in the realms of telehealth and remote monitoring.

Telehealth & Remote Client Monitoring in SOAP Notes

• Telehealth services: In telehealth appointments, the Subjective section becomes even more crucial, as healthcare providers may rely more on client-reported symptoms in the absence of traditional physical exams.
• Remote monitoring: Whether offering telehealth or in-person services to clients, the Objective section of your SOAP notes might include data from remote monitoring devices.

Adapting SOAP notes to today’s healthcare challenges not only ensures the notes remain a relevant and powerful tool but also enhances client care in an increasingly digital and interconnected healthcare environment.

Conclusion

As healthcare continues to change, our approaches to documentation should too. Embracing ongoing learning and adaptation in documentation practices is crucial for healthcare professionals striving to provide the best possible care.

Power Diary offers a platform to create secure, professional SOAP notes, tailored to the needs of healthcare practices. Our system is designed to make documenting care as seamless and efficient as possible, allowing you to focus more on your clients and less on paperwork.

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