Subjective, Objective, Assessment, and Plan notes, which are more commonly known as “SOAP” notes are a documentation process used by a wide range of healthcare providers to write quick notes in a patient’s chart. This helps to document each patient encounter in their medical record is a comprehensive workflow practice that begins with appointment scheduling, patient check-in and continues on through the examination, check-out, rescheduling, and eve the medical billing process. In this way SOAP notes serve as a general cognitive framework for physicians to follow throughout the assessment and treatment process.
SOAP notes were originally created as a way for physicians and therapists to approach complex patients with multiple problems in a highly organized way. Over the course of the last 50 years SOAP notes have evolved to become a common communication tool between interdisciplinary healthcare providers as a way to document a patient’s progress.
Subjective
Refers to the qualifiable or descriptive information expressed by the client themselves, or their family, or an assigned guardian. It is based on revelation, as well as feelings, and observations. Subjective notes might also include things like quotes of things the patient has said as well as attention, or engagement level.
Objective
Refers to the quantifiable or measurable information including things like the specific objectives that are being used to meet goals as well as IEPs or 504 plans.
Assessment
This refers to the section where the provider assesses and documents their synthesis of the subjective and objective sections in the collected SOAP notes. This can include the effectiveness of treatment as well as other measurable factors in the overall treatment plan.
Plan
Is for writing the next in the patient’s treatment plan. This typically includes any short and long-term goals, as well as other important factors like frequency, and length of therapy. It might also include proposing any possible treatment plan changes that might need to be made in the future.
Where Do You Find SOAP Notes?
You also tend to find SOAP notes in a patient’s medical records, including the electronic medical records. They help different providers from different backgrounds to understand and further assess a patient’s needs. Many times SOAP notes are used as a sort of template to help guide the information collection process.
It’s also worth noting that pre-hospital care providers including emergency medical technicians also use a similar format to communicate patient information to emergency department clinicians. In this way the SOAP notes provide the physicians with a standardized way to organize the patient’s information while also helping to reduce confusion when patients are seen by various members of healthcare professionals.
Who Uses SOAP Notes?
SOAP notes are used by a wide range of physicians, specialist, and disciplines from general medical practitioners to behavioral healthcare professionals and even veterinarians, to help monitor a patient from their initial visit all the way through follow-up care, as well as an efficient means of communicating with other physicians and specialists who might also need to diagnose, assess or treat the patient.
Why Are SOAP Notes Important?
SOAP notes play a critical role in documenting a patient’s condition, needs and treatment strategy. It is especially helpful for ABA therapy sessions as they can also be used to substantiate billing claims that are created for insurance providers and public payer institutions.
SOAP notes also help to communicate the patient’s condition to an interdisciplinary team as part of the physician’s rationale for ongoing services. They include important things like observations that aren’t always subjective as well as those that are truly measurable.
Tips For Writing Better SOAP Notes
Writing SOAP notes should not be done during your treatment session as it can distract both the physician and your patient from the actual treatment process. It’s ok to jot down short personal notes during a session to help you write your SOAP notes later. Though, as the physician or therapist you should do your best to use short acronyms. This includes key information like:
- Onset
- Location
- Duration
- Character
- Alleviating or Aggravating Factors
- Radiation
- Temporal Pattern
- Severity
When it comes time to write the formal SOAP notes do your best to back up everything you write in your objective section including any and all supporting data. This includes both short and long-term areas of concern.
Do your best to synthesize the information and data in your subjective and objective sections to help you make an unbiased evaluation that is clearly data-driven. Then make it a point of practice to carefully track your client’s progress through a systematic review of past appointments. This type of assessment process helps refine the patient’s treatment plan while also helping to track their progress or potential setbacks. It can also help to catch recurring patterns.
Common SOAP Note Writing Mistakes
There are a few common mistakes that sometimes occur when writing SOAP notes. Developing good practices will go a long way toward making sure that your SOAP notes are clear, comprehensive, and easy to understand for other physician or medical billing coders.
Don’t Procrastinate SOAP Note Writing
One of the most common SOAP note mistakes made by physicians and therapists the world over is waiting to write SOAP notes until later. This can lead to errors or lapses in information that make it harder to recognize the patient’s long-term treatment challenges. You should always do your best to write SOAP notes immediately following the treatment session.
Confusing Subjective & Objective Sections
Another common mistake in writing SOAP notes is to blur the line between the qualifiable subjective and quantifiable objective sections. This makes an assessment without synthesizing the information from those sections, and making a plan of treatment without knowing the difference between the overall objectives and the long-term treatment goals.
Support All Opinions With Data-Driven Facts
Any time you write an opinion in a SOAP note you should do your best to back it up with supporting facts. This includes the subjective section where you can still provide data-driven evidence for your observations.
