SOAP NOTE

Use A Structured Format
A structured format makes it easier for readers to understand what they are reading without carefully reading every word or sentence. It is much more efficient to quickly scan a document and get the gist of what is going on. 

Having a standardized SOAP template is a great way to adopt a structured format within a facility. It also facilitates the standardization of assessment methodology making for a more streamlined and organized assessment process.

Use Clear, Concise Language 
It is especially essential when writing SOAP notes, as clarity and conciseness ensure that everyone who needs to understand the documentation can do so easily. 

Avoid Excessive Medical Jargon
Jargon and technical language limit the accessibility of documentation by those who might not be as familiar with those terms. 

Be Clear
Ambiguity can make it more difficult for readers to understand what is going on, resulting in confusion and misinterpretation of one’s words. Use simple language and stick to one meaning per word to avoid any confusion. 

Use Active Voice
Active voice makes one’s writing more concise and easier to read. It also sounds more assertive, which can be helpful when one needs to make a strong point. 

Active voice is essential when writing the plan for the patient. Information conveyed to the patient must retain its importance as well as clarity. Passive voice adds a muddying effect to information sharing and creates ambiguity. Remember tip four about being transparent. Active voice ensures one does not make that mistake.

Format Notes For Easy Reading
Use headings, lists, and other formatting features to make notes easier to read. It will help prevent confusion and ensure that readers can get the essential information quickly and easily.

Use Standard Abbreviations
Standard abbreviations make it easier for everyone to understand the documentation, as they are universally understood. It avoids any potential confusion or misinterpretation if one uses non-standard abbreviations.

Many common abbreviations are used by healthcare professionals on documentation. However, including the appropriate terms is vital to the legibility of the document. Take the EMR format for example. In many cases in EMR, vital time is saved by the use of the appropriate abbreviations. Just ensure that the appropriate terms are used for the future understanding of those who may require the document for a future assessment.

In the professional world, a SOAP note serves two purposes.

SOAP notes provide written proof of what you did and observed.
This is important because it could help you keep track of scores or goals, might be required from your employer, and in many settings, might be crucial to getting your work reimbursed by insurance. It also makes sure there is proof of what happened in case your documentation or work comes under review. Sometimes SOAP notes are even brought into court! It is very important that your SOAP notes are accurate!

SOAP notes are a way to communicate with your teammates.
SOAP notes are a common way for healthcare and other teams to organize information they need to share with each other when they are working together or taking over where someone else left off. SOAP notes should be clear, well-written, and easy to follow so that your team can find the information they need.

WHAT IS INCLUDED IN A SOAP NOTE
S-Subjective

O-Objective

A-Assessment

P-Plan

S-Subjective
Subjective means personal and not measurable. The S section is the place to report anything the client says or feels that is relevant to their session or case. This includes any report of limitations, concerns, and problems. Often living situations and personal history (ex. PMH or Occupational Profile) are also included in the S section. [NOTE: This does not include any answers to an evaluation or screening such as pain scale.]

Ex. Client reported _____________ problem, feeling, action, etc.
O-Objective
Objective means that it is measurable and observable. In this section, you will report anything you and the client did; scores for screenings, evaluations, and assessments; and anything you observed. The O section is for facts and data. The O section is NOT the place for opinions, connections, interpretations, etc.

The O section might begin with an introductory sentence outlining how long the session was.

Ex. Client participated in ____minute session in _______setting for skilled instruction/intervention in _____________.
Sometimes, the O section then gives an overview statement summarizing observations and client deficits. This is optional.

Ex. Client presents with ___________ (disease, disability, deficit, etc.).
Next is the most important part of the O section—what happened and what you observed. There are multiple ways to organize an O section.

Chronologically
This might be the easiest way to organize it, especially if you are new to SOAP notes.
Chronological order means you write what happened in the order it happened.
Ex. First the client…..Second, the client…….Next, the client…..
If you organize it chronologically, make sure to include all treatments and relevant observations but remember that you do not have to include every detail of what happened.
Categorically
Categorical means organizing the O section according to categories of things that you and the client did or that you observed.
Ex. Category/Deficit #1
Example 1
Example 2
Category #2
Example 3
Example 4
If you organize it categorically, sometimes it is helpful to group things into broad categories because there may be overlap between one section and another.
Evaluation Findings
If the session was an evaluation, the SOAP note may look a little different
An evaluation SOAP note must include all scores from the eval. This could include:
Summary of Screening results
Assessment/Test/Evaluation results
Pictures
Observations during evaluation
Evaluation scores can be listed in bullet points or in paragraph form.
Ex. Name of Assessment
Category: Result
Observations
Sometimes it makes sense to incorporate observations throughout, but some people find it helpful to create a section in their O-section for observations
A-Assessment
The A section is where you describe and explain why things happened and what might be going on. This is the appropriate place for informed opinions, theories, explanation, and (last but not least) interpretations! The most important thing to remember is that the A section is where you make sense of what you wrote in the O section and S section. It should not include any new information, just like your O section should not include anything besides facts.

Many A sections include 3 P’s plus needs:

Problem or Cause-Effect statements
These statements provide an interpretation and explanations of patient’s problems, of evaluation findings, and of observations.
A statement of progress
Sometimes we can compare the scores or observations from our O section to what we have seen in the past.
This is important because someone reading your SOAP note now understands whether your O section shows the patient is making progress or not
A statement of potential
While it is easy to focus on the problems and issues, we also want to highlight things in the previous section that indicate the potential this client has.
This could include the client’s strengths, their support system, their attitude, etc.
A summary statement of needs
This is often a justification for services or a justification for discharge.
Example:

Problems: ______________(condition/deficit) causes client difficulty with ________________ (occupation).

Potential: Client shows rehab potential to make progress as indicated by ______________ (supports/client factors/ etc.).

Progress: Client demonstrated progress in _________ (during session or throughout therapy).

Justification of services: Client would benefit from skilled intervention/instruction focused on __________________________ (tasks/strategies for specific occupations).

P-Plan
The P section is where you answer “Now what?” Knowing the information from the sections above, write your suggestions for treatment, referrals, resources recommended, and discharge plans. For an initial eval session, this may also include long-term and short-term goals. Remember that all information in this section should connect back to your 3 P’s and Needs from your A section.

Example:

Continue tx ___min #x/wk for # wks to work on ____________ (intervention) for _____ (goal/occupations).

Referral to___________ recommended to address_______________.

Family provided with resources including _______________________.

SOAP NOTE TEMPLATE
S- Subjective
Client reported _____________ problem, feeling, action, etc.

Client’s home situation or medical history if they share

O-Objective
Initial statement: Client participated in ____minute session in _______setting for skilled instruction/intervention in _____________.

What Client Did

What you observed

Assessment/Evaluation/Test results

A-Assessment
3 P’s and Needs

Problems: ______________(condition/deficit) causes client difficulty with ________________ (occupation).

Potential: Client shows rehab potential to make progress as indicated by ______________ (supports/client factors/ etc.).

Progress: Client demonstrated progress in _________ (during session or throughout therapy).

Needs/Justification of services: Client would benefit from skilled intervention/instruction focused on __________________________ (tasks/strategies for specific occupations).

P-Plan
Continue tx ___min #x/wk for # wks to work on ____________(skills/activities/intervention) for _____ (goal/occupations).

Referrals and Recommendations

OR Discharge plan