soap notes screenshot
21 April 2017

SOAP (Subjective, Objective, Assessment, Plan) notes are an essential component of providing care and treatment for patients. Its 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 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 Overview 

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. 

  • O – Onset – When the condition started. 
  • L – Location – Where is the condition located.  
  • D – Duration – How long has the condition lasted.  
  • C – Character – Description of the condition.  
  • A – Alleviating/Aggravating Factors – What makes condition better or worse.  
  • R – Radiation – Does the condition move or stay stationary.  
  • T – Temporal Pattern – Is the condition worse during specific time of day 
  • S – Severity – Rate the pain on a scale of 1-10. 

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 breviewing the subjective and objective sections separatelyReviewing 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.  

1. Think about the purpose of the note

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:  

  • Ensure proper billing from insurance companies 
  • Provide rationale for ongoing services.  
  • Create a consistent and effective method of treatment for every patient 
  • Offers a balance between patient input and clinician guidance.  

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.  

Graphic of ClinicSource therapy SOAP notes template

ClinicSource features therapy SOAP note formats that make your therapy documentation easier than ever

2. Complete notes within a reasonable timeframe

Complete notes as soon as possible following treatment sessionsCompleting 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. 

3. Double-check key details within your SOAP note

Align the details of your SOAP note templatesDouble (or triple) check these crucial details:  

  • If treatment was provided for a 60-minute session, the start time, end time, and units billed must match up accordingly 
  • Confirm all CPT codes match up with the billing statement.  
  • Patient names and diagnosis codes are accurate throughout 

By using ClinicSource templates, accurate information flows automatically from section to section, reducing the chances of clerical errors.  

4. Be mindful of meaningful goals and objectives

SMART (specific, measurable, attainable, relevant, and timely) goals keep SOAP notes effective and consistent over timeSMART 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 

5. Compare patient performance across sessions

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. 

6. Don’t underestimate home education programs

Make sure to document home education and carryover programs in SOAP notesThis 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.  

Free Live Demo Now Available from ClinicSource!

Looking for an EHR solution so you can write and manage SOAP notes? ClinicSource is the answer.If you’d just like to see this time-saving EMR/practice management software in action, contact one of our experts today for a free live demo!

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