SOAP (Subjective, Objective, Assessment, Plan) notes are an essential component of providing care and treatment for patients. It’s vital to document data and information from every patient encounter. Therapists must use SOAP notes to monitor and document patient progress, log services, and communicate patient information to other professionals.
With a high volume of daily patients, it’s easy to feel overwhelmed by therapy documentation software. This SOAP notes overview and actionable pointers will help you write notes in a clear and efficient manner.
SOAP notes were first introduced by Dr. Lawrence Weed about 50 years ago; their creation revolutionized the medical industry as the first proper method of documentation. The exercise varies by field and allows plenty of room for customization, but there are four universal components.
Subjective – The subjective section is for patient input. These are statements provided by the patient about their symptoms and current condition. Some healthcare professionals rely on another acronym for proper subjective documentation. The most common is “Old Carts.”
Objective – The objective section is about measurable results and quantitative data. All statements under objective should include a supporting piece of data. Record the conclusions about this data separately.
Assessment – The assessment section is an analysis of the subjective and objective results. Make unbiased, data-driven decisions by reviewing the subjective and objective sections separately. Reviewing the assessment section from previous visits is an ideal way to track progress and make sure details are not lost over time.
Plan – The plan section is about treatment and rationale. This includes the next steps for the patient, take-home assignments, and anticipated agenda for the next session.
The tedious nature of SOAP notes can erode their importance. In addition to communicating patient information and progression to other professionals, SOAP notes serve a variety of purposes:
ClinicSource templates provide a consistent format for documentation depending on the treatment provided. The result is a cohesive and well-structured SOAP note every time.
Complete notes as soon as possible following treatment sessions. Completing notes in a timely fashion means more accuracy. Perhaps more importantly, falling behind on documentation can delay insurance reimbursement.
ClinicSource templates pre-populate basic patient information, allowing clinicians to spend less time typing repetitive information and more time documenting session specifics. The time savings means more quality time with patients, which benefits patients, and your practice’s bottom line.
Align the details of your SOAP note templates. Double (or triple) check these crucial details:
By using ClinicSource templates, accurate information flows automatically from section to section, reducing the chances of clerical errors.
SMART (specific, measurable, attainable, relevant, and timely) goals keep SOAP notes effective and consistent over time. SMART goals ensure that all parties (patient, parents, insurance companies, physicians, etc.) understand the mission of your work.
In a ClinicSource SOAP note template, goals and objectives from a patient’s treatment plan automatically populate in the Objective portion of the note, making it easy for clinicians to enter specific data points and track progress.
A lone data point is not useful. However, when viewed next to previous data, it illustrates patient progress or setbacks.
ClinicSource SOAP notes make it easy to add a comment about data trends to the Assessment portion of the note. In this section, be sure to analyze and interpret your data, especially as it relates to a patient’s performance. Clinicians can generate a Progress Summary Note, which instantly graphs data from a selected time frame.
Make sure to document home education and carryover programs in SOAP notes. This is an important exercise for patients to practice their developing skills. Additionally, insurance companies often make this a requirement for billing.
Document all recommended strategies and interventions with directions on home implementation.
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