Anyone working in private practice knows the importance of keeping detailed and thorough notes. They’re an integral part of treatment. But for many years, there wasn’t a standardized format for documentation.
In the 1950s, physician Lawrence Weed recognized that doctors, interns, and other care providers are almost always dealing with multiple complex issues at once, often with multiple patients. So he created a standardized method of documentation that would simplify treatment plans for himself and other providers. At the time, the method he created was called a problem-oriented medical record (POMR). Today, it is referred to as the SOAP note.
POMRs and the subsequent widespread use of SOAP notes have revolutionized the way that providers organize their client data by creating one format that any provider can look at and immediately decipher. Over the years, SOAP notes have been adopted by health and wellness providers in various other industries—not just the medical field.
In an industry where interdisciplinary care is becoming more and more common, a standardized way to communicate treatment streamlines the amount of work providers have to do. It also makes it easier for clients to receive seamless, continuous care.
What is a SOAP Note?
The standardized format of the SOAP note template guides practitioners through assessing, diagnosing, and treating a client based on the information in each of the note’s sections.
This section is for you to record the client’s subjective reporting of their concern. It’s good practice to use your client’s own words, or the words of someone close to your client (like their parent or spouse). Here your client can tell you the main concern that brought them to you in the first place, and you can ask clarifying questions to understand how long it’s been bothering them, if it’s more severe at some time than others, and if anything makes it better or worse. This is also the place to record the client’s subjective description of their mood, and anything that has changed in their life since the last visit that is related to their treatment.
After you gather the subjective information, the “O” section of the SOAP note is where you put your objective observations of your client, as well as information about what occurred during this session. This can include observations of client behaviors, the treatment methods you’ve used, client responses to those methods, any measurable outcomes throughout the course of treatment.
This part of the SOAP note is where you use your clinical expertise to connect the dots of the previous two sections. Describe any analysis of the subjective and objective information, your interpretation of sessions you’ve had, and your client’s progress toward treatment goals. Any decisions about changes to the client’s diagnosis or treatment plan can be noted here. You can compare your latest session to previous ones, and note if there are other areas your client needs improvement in.
To wrap up your SOAP note, use this section to write what’s next for your client’s treatment. You likely already have a treatment plan written, so you don’t need to repeat your entire plan. This section is just for immediate next steps, and how those steps will move your client closer to your goals. Based on your assessment section, this is where you can adjust next steps as needed.
What Are the Benefits of Using SOAP Notes?
With the rise of digital note-taking, it’s easy to have a large library of notes and paperwork for each individual client. This may work for you, but may be harder to send to another provider if needed. A big benefit of the SOAP note is its brevity. Each section is clearly labeled, and each section is short and to the point. Another provider could easily pick up where you are in the course of treatment at a glance—and it’s helpful to remind yourself where you are as well.
SOAP notes were created to standardize the collection of client data across practices, and the prescriptive nature of each of the sections reflects that. However, there has been some discussion about whether changing the order of the sections might improve the SOAP note’s usability further. One study found that reordering the note to be APSO made the content quicker to find and easier to read—as the information most relevant to ongoing care was at the top of the note.
As with many things in private practice, SOAP notes and other note templates can be adjusted to work best for you and your clients. If the order or sections of the SOAP note don’t work for you, you can adjust them or use a different format. The point of a template is to make it easier for you to take client notes, not harder. Make sure you’re using a process that allows you to focus your time and energy where it matters—with your clients.