SOAP Note Cheat Sheet

Think about it this way - you just came out of a very intense therapy session and your mind is full of insights and observations. However, when you sit down to write about the session, writer’s block hits you. Does this sound familiar?

Well, don’t fret my fellow mental health warriors! SOAP notes are here to rescue us today (and our sanity).

SOAP notes are no ordinary paperwork; they’re your secret weapon for providing excellent care. Think of them as clinical documentation’s Swiss army knife: versatile, efficient, and indispensable. Whether you’ve been doing this for ages or recently joined the field of therapy by becoming a newbie, being good at SOAP notes will transform your work.

Then grab yourself some favorite drink and turn on that comfy mood switch as we go into the world of SOAP notes where organization meets creativity and documentation becomes a piece of cake!

In the quick pace of mental health care, efficient documentation is not merely red tape; it is a vital part of high-quality client care.

But what are SOAP notes anyway and why do they matter?

SOAP, an acronym (meaning Subjective Objective Assessment Plan) was coined by Dr. Lawrence Weed in the 1960s in order to have a better method for documenting patient encounters. In the area of mental health, there are several reasons why you may want to use SOAP notes:

• It captures each session in detail.
• Helps one monitor progress over time.
• Enhances communication among medical practitioners.
• To act as legal records for service provided
• They guide treatment planning and case formulation

Now let us get into the different aspects that make up the SOAP note and how you can write effective notes that will be helpful to both your clients and yourself.

In the section below we'll break down each part of SOAP and provide you with some tips and examples!

S - Subjective:

What is your client telling you?

Subjective is all about the feelings and words of the client that explain how they feel at a certain point in time. It’s the social interpretation of it: direct and unadulterated story-telling is what its author offers.

This part of the SOAP note is all about your clients - what they're experiencing and how they're feeling.

Some of the things to remember when writing Subjective notes:

• Use the client's own language wherever possible - it adds credibility!
• Read over the previous notes and focus in on anything new or different since the last session.
• If it's a new client, include in the notes a little about why they are there for their first visit.

Example:

"Jane reports feeling 'overwhelmed and anxious' about the job interview she has coming up. She states that she is, 'I am not able to sleep because my mind won’t shut up”

Pro Tip: To give full quotes where especially appropriate and helpful, or as indicating the client’s precise words.

O - Objective:

What are you seeing?

At this point, you lay on your detective cap to jot down what you can observe about your client. In the objective section, information regarding the clinician’s perceptions of the client observed in the specific session is written. It should be factual as opposed to opinionated.

Some of the things to remember when writing objective notes:

1. Be factual and only write down things you see or can count.
2. When appropriate, you would list any test scores or scales that are part of an evaluation.
3. When appropriate, you would list physical observations (appearance or behavior).

Example:

"Jane appeared tired, she had dark circles under her eyes, fidgeted throughout the session, and spoke quickly. She scored a 15 on the GAD-7, indicating moderate anxiety."

A - Assessment:

What's your professional opinion?

Now it is your time to shine! You will use your professional opinion to make sense of the S and O.

Some of the things to remember when writing assessment notes:

1. Begin connecting the S and O information.
2. Write a diagnosis or clinical impression.
3. Write any changes in the client's condition.

Example:

"Jane is describing symptoms consistent with Generalized Anxiety Disorder. She is concerned about an upcoming job interview. Current stress is affecting her sleep and everyday living. She is motivated to find strategies to cope."

Be prepared to chart your treatment and what you are going to ask your client to do between sessions.

P - Plan:

What’s next?

The action plan section elaborates on the plan from the evaluation made in the previous section of the paper. It should be clear, measurable, relational, and contextual to the client’s needs.

Some of the things to remember when writing plan notes:

1. List your interventions in a detailed manner.
2. When appropriate, list any consults or referrals.
3. Note the date and goal for the next appointment.

Example:

“1. Continue weekly CBT and focus on challenging anxious thoughts.

1. Introduce progressive muscle relaxation for sleep.
2. Daily thought record to track anxious triggers.
3. Next appointment 7/21/24 to review coping with the interview.”

Here is a SOAP note template for you to have an idea of how to go about writing the notes.

“But why bother using SOAP for session notes when I can just write notes the way I want to?”

Here is how SOAP notes help you become a better therapist:

• Continuity of care: Easily pick up where you left off last session and be able to put that information to use.

• Pattern recognition: Observe any pattern in how your client is progressing over time.

• Treatment planning: Use what you learn to inform your treatment planning process and adapt your approach accordingly.

• Outcome measurement: Monitor systemically their progress towards treatment objectives.

Tips for Effective SOAP Notes

1. Be concise: Include relevant information without unnecessary details.
2. Use objective language: Avoid subjective interpretations or judgments.
3. Be specific: Use concrete examples and observations rather than vague statements.
4. Maintain professionalism: Use clinical terminology and avoid colloquialisms.
5. Ensure confidentiality: Only include necessary identifying information.
6. Be timely: Complete notes as soon as possible after the session.
7. Focus on clinical relevance: Include information that informs diagnosis and treatment.
8. Document risk: Always note any risk factors or safety concerns.
9. Use quotations judiciously: Direct quotes can be helpful but use them sparingly.
10. Proofread: Check for errors or unclear statements before finalizing.

Dos:

✅ Be concise but thorough

✅ Use appropriate language

✅ Focus on pivotal information

✅ Update treatment objectives regularly

✅ Consider client strengths and progress

Don'ts:

❌ Include subjective judgments

❌ Use abbreviations that others may not understand

❌ Include excessive details

❌ Forget to sign and date your note

❌ Neglect to discuss safety risks

SOAP notes have become an essential part of the mental health professional’s toolkit, providing a systematic approach to session documentation and improving both clinical practice and client care. As we have observed in this cheat sheet, each part of the SOAP format – Subjective, Objective, Assessment, and Plan - plays an important role in capturing the essence of a therapy session and directing future interventions.

It is important to remember however that SOAP notes are not an end in themselves but rather they are a means to an end. The main focus should always be on the therapeutic relationship and the well-being of a client. While comprehensive documentation is necessary it should not come at the cost of being present during sessions. This requires skill that develops over time with experience and deliberate practice.

Nowadays, SOAP notes have gone digital. Many times digital platforms provide a SOAP note generator with templates and prompts based on the SOAP format thus simplifying the documentation process. Even as this increases efficiency, there must still be room for customization for each note so that each one captures unique aspects of clients or sessions.

While SOAP notes are an effective tool for mental health documentation, it is important to understand their limits. While the structured approach is efficient at organizing information, it might seem confining for complicated instances that do not cleanly fall into categories. This rigidity may result in an oversimplification of complex client experiences or therapeutic encounters. The time-consuming nature of thorough SOAP notes can be difficult for busy professionals, possibly taking away from direct client care time. There is also a risk of over-reliance on the format, which may override professional intuition. SOAP notes, which are clinician-centered, may not adequately reflect the client's voice or viewpoint on their development. Recognizing these limits enables professionals to utilize SOAP notes sparingly, adding to them with alternative documenting methods as needed to maintain thorough and client-centered treatment.

The writing of SOAP notes by mental health professionals is a lifelong endeavor. This skill brings together knowledge in clinical practice, keen observation, and clear communication. SOAP notes are more than just records when used properly; they become powerful tools for enhancing therapeutic outcomes, fostering professional growth, and ultimately, changing the lives of our clients. As we further refine how to use SOAP notes, we are not only contributing to our own practices but also to the mental health field as a whole thus promoting higher standards of documentation which translates into better care for all.