If you’re a mental health professional, you’ll understand how challenging it can be to take comprehensive clinical notes and keep a consistent structure from session to session. It’s one of the reasons that using SOAP notes for mental health has become the golden standard. They provide a framework for the session and ensure that you don’t get too far off-topic or forget to cover an essential point.
But staying consistent and up-to-date with your progress notes presents its own set of challenges. Busy practice with competing priorities and a commitment to that elusive work-life balance mean that you need to find the best, most efficient way of taking mental health progress notes.
Having worked with thousands of mental health practices over the years, we’ve picked up a couple of tips on how to effectively take SOAP notes. These tips are going to make note-taking easier and quicker because they (finally) offer some clarity on what should be included, so you don’t end up down a rabbit hole of indecision. They’re also going to make sure that you’re offering the best level of support to your clients while ensuring that you’re protected in the event of a review.
But before we dig in, it’s helpful to have a clear overview of the SOAP methodology and why they’re so important.
What are SOAP Notes?
Most mental health professionals around the world use the format known as “SOAP notes” for taking mental health progress notes. It’s a simple concept with progress notes in the SOAP format allowing the reader to easily scan and find information about the different aspects of the session. But, unfortunately, many tertiary education centres don’t include training on SOAP notes, so most mental health professionals tend to pick up progress note-taking skills from mentors and fellow clinicians. This often means that, even if you’re using the SOAP framework, there’s still very little uniformity. Some professionals won’t include enough detail where others will contain much more information that is needed, or even helpful.
SOAP is an acronym that stands for:
- S – Subjective, this section covers information that the client shares in the session, such as their presenting problem or their chief reason for coming in. You may want to use direct quotes and all topics that you covered during the session.
- O – Objective, this is where you include all the factual information such as a diagnosis, signs and symptoms, the client’s mood or affect, and their appearance.
- A – Assessment, here you will document what you noticed in the session and your interpretation of both objective and subjective information. This may include your impressions of their mood, risk of harm, and progress towards goals.
- P – Plan, this section documents the next step for the client including what you plan to do in the next session, the frequency and duration of therapy that you anticipate, short and long-term goals, and any homework that you’ve given your client.
Why are SOAP notes important?
Running a mental health practice can be overwhelming. From dealing with challenging clients to allocate a marketing budget – it often feels like there are fires that need putting out every direction you turn. And that can start to impact the quality of care that you offer your clients. While you may have the training to ensure that you remain fully present during the sessions, it’s completely understandable if, by the end of the day, you’re completely exhausted and writing you your progress notes is the last thing you feel like doing.
Unfortunately, it’s one of the most vital areas of your practice. In a previous article, we covered what not to do when taking mental health progress notes, looking at seven common mistakes that mental health professionals make. This helps us understand a bit more of the ‘why’. Good mental health notes (using the SOAP methodology) are going to:
- Protect you in the event of a review by a standards committee in the event of an adverse outcome.
- Help other health professionals who need to review your notes.
- Ensure that you offer your clients the best levels of care.
- Ensure that you are compliant with professional association record-keeping guidelines and country-mandated record-keeping laws.
5 Things to Remember with SOAP Notes for Mental Health
Given the many different responsibilities of a mental health professional, it can help to work from a framework that’s clearly defined. Where you may not have a clear idea of the best way to write up your notes, we’re here to help you get your head around the most important aspects of mental health progress notes. To lighten the load a little, we’ve summarised the top 5 things to keep in mind when you’re writing up your notes:
#1 Get your timing right
You need to find the right time to write up your progress notes. For most mental health professionals, it’s not practical or helpful to do them while you’re in session with your client. During the session time, you should rather be taking personal notes that you can use to fill out the SOAP framework later. But it’s a balance; you also don’t want to wait too long either. Ideally, SOAP progress notes should be written up a few hours after the appointment on the same day so that you don’t forget your observations, but have the benefit of a bit of time to solidify your perceptions of the session.
#2 Use a professional, concise writing style
Try to avoid informal language, colloquialisms, non-standard abbreviations, and slang that may impact the professional tone of your notes. A professional tone will improve the authority of your notes, as well as ensuring that they are crystal clear for someone else to review them. Steer clear of wordy phrasing where possible as it makes the notes more difficult to understand, especially for another professional who is doing a quick overview of a session.
#3 Stay neutral
To maintain an objective stance, your SOAP notes for mental health sessions need to be free from judgement. They should accurately describe scenarios that give insight into the client’s behaviour rather than making unsubstantiated statements without evidence. It also helps to remove words like “very” and “a lot” from your note-taking as you’ll be forced to describe the client’s behaviour rather than making assumptions about their internal state.
#4 Get the details right
Your notes will be easier to follow and you’ll come across better if you pay attention to tense, avoid pronoun confusion, and do a simple spell-check (if the notes are electronic). If you’re quoting your client, place their exact words in quotation marks. Then, be careful to get the dates and timing of events right, as well as the spelling of names.
#5 Use an accepted procedure for correcting errors
Mistakes happen, even if you triple-check your work, and it’s not the end of the world. But what is important is how you correct those errors. Avoid the temptation to alter records with scratch-outs, an eraser, or correction fluid. Any omissions or deletions may create suspicion in the mind of the person reading the notes. The best way to make corrections is to use a strikethrough (a single line:
the client said), write ‘error’ next to the correction, write in the correction, and then initial it. This allows the reader to see:
- The original notes;
- The corrected information;
- Who made the correction (it should always be you making corrections to your own notes).
Whether you’ve been writing progress notes for years, or are just starting out and could do with some help, there’s always scope to write better SOAP notes in mental health. Given that many mental health professionals don’t necessarily get training in how to write progress notes, we’ve covered the five most important areas to focus on to ensure that you have the basics in place.
If you know someone working in mental health who could do with some support, why not forward on this article. With the focus always on helping clients, SOAP notes in mental health are one of the most underrated ways to offer the best levels of care and achieve better outcomes.