Documenting client interactions and progress are vital components of treatment. It is also critical to the health of your practice. As such, it’s essential to document every encounter. Writing SOAP notes to accompany every session is one common and effective method for doing this.
What are SOAP notes?
The Subjective, Objective, Assessment, and Plan (SOAP) note is an acronym referring to a widely used method of documentation for healthcare providers. These notes should be brief, focused, informative, and always in the past tense.
Need a refresher on what each letter of the acronym stands for and mistakes you can avoid at each step? We’ve reviewed source materials and created a guide with this in mind.
Describe your impressions of the client and support those impressions with observed facts. Impressions should include descriptions of the client’s interactions, feelings, and performance. This may also include personal or medical issues that may impact or influence their performance. Questions, comments, and concerns from your client or their caregiver/loved one are particularly important to focus on as these will be observed fact to support your impressions.
Example: Client was alert and attentive during therapy. He had great motivation and willingness to participate. He had completed his homework and said, “I’m ready to work even harder today.” Client’s mother stated that client was excited to come to therapy today and that he had slept well the past few nights. Mother stated that she had completed the at-home exercises with him every day this week, and she feels that this is building his confidence to work even harder.
What to avoid: Do not include statements without supporting facts. In the example above, just stating that “Client was willing to participate” is an opinion until you provide facts to support this observation. Consider only information that you feel is relevant and statements from the client, loved ones, or teachers that can be attributed to your client’s mood, motivation, awareness, and willingness to participate.
This section is where you document measurable outcomes about your client’s performance, including test scores, percentages for any goals worked on, and quantitative information.
Example: Produced /ch/ correctly in 17/25 (68%) initial sentences without any cues.
What to avoid: Do not include general statements without supporting data. “Client responded well to non-verbal cues” would be your impression of the therapy session and would work well as a point to elaborate on in the subjective section. This section is all about quantitative information. You should not give excessive supporting data like describing every activity your client participated in. “Client produced /s/ correctly when provided visual cues, tactile cues, naming picture cards, and imitating words.”
Describe your analysis, interpretation of the session, and your client’s progress. Document strengths and areas of improvement, and compare performance to previous sessions.
Example: “Client’s progress on the /ch/ production objectives improved from 50% accuracy the last session to 80% accuracy using visual cues. Without the use of visual cues, performance decreased significantly.”
What to avoid: Do not rewrite what you stated in the Subjective or Objective section. This is where you step back and look at the client’s progression or regression over time and assess what factors attribute to this change
Create an outline of next steps in your client’s treatment. State all activities, objectives, or reinforcements that you are changing. If your client continues to get low scores, then consider a new plan to get closer to their goal.
Example: “Continue working on final consonants and remove all cueing during the /ch/ activity to see if successful production of the sound can be maintained” or “continue with current treatment activities.”
What to avoid: Do not rewrite your entire treatment plan. Your client’s goal is already outlined in your treatment plan, and this section is where you should be specific about what your next steps are to get your client closer to achieving that goal. Based on your assessment of the client’s progression, this is where you would adjust cues if needed.
An ounce of prevention
While documentation can sometimes be viewed as an afterthought, SOAP notes are a widely accepted format that keep your process clean and consistent. Used correctly, they ensure proper documentation, providing a framework for evaluation as well as clinical consideration.
Avoid these outlined pitfalls and, in closing, always remember a phrase often used in medical training —
“Yes, it’s true, if it’s not documented, it didn’t happen!”*
*Moore, B. (2013), Documentation issues. In R. Lubinski & M. Hudson (Eds.), Professional issues in speech-language pathology and audiology (pp. 420-443). Clifton Park: Cengage.