2.1: SOAP Notes

What’s a SOAP note?

According to the journal Academic Medicine, the SOAP format was developed in the 1950s by Lawrence Weed, a professor of medicine and pharmacology at Yale University.

Originally referred to as a problem-oriented medical record (POMR), the SOAP note evolved, and today it’s widely used by practitioners across many healthcare disciplines—including mental health professionals—to document and organize findings in an objective way.

Though the specific information and length of these documents varies by discipline, it’s important to learn how to write SOAP notes because they all follow the same basic structure. This standardization is easily recognizable by providers in other specialties—making it easy to coordinate care for your clients if needed.

How to write a SOAP note

Learning how to write SOAP notes is generally a straightforward process because it always follows a specific and precise structure. However, it does take some practice.

SOAP notes include four headings that correspond with each letter of the acronym:

• Subjective
• Objective
• Assessment
• Plan

The notes and records you enter under each heading will depend on your clinical specialty, who your client is, and what you’re working on during your sessions together.

We’ve broken down the order of how to write SOAP notes and provided suggestions for what to include in each section as recommended by a review of peer-reviewed articles in StatPearls.

Subjective

This section is for subjective reporting of how your client says they are feeling during the session and what they report about their current symptoms. It can also contain information gathered from family members and reviews of past medical records.

Many mental health practitioners focus on what’s known as a “Chief Complaint”(CC) or the presenting problem in this section.

Even if the client reports multiple CCs, it’s important to try to identify the most compelling problem so that you can ultimately provide an effective diagnosis.

Some general areas of inquiry as you try to identify the primary CC may include: history of present illness, medical history, review of systems, and current medications.

Here are some questions to ask to help uncover your client's Chief Complaint:

1. Describe your symptoms in detail. When did they start and how long have they been going on?
2. What is the severity of your symptoms and what makes them better or worse?
3. What is your medical and mental health history?
4. What other health-related issues are you experiencing?
5. What medications are you taking?

Make sure any opinions or observations you include in the section are attributed to who said them—whether it’s yourself or your client. Because this is a subjective section, you don’t want to pass off any of this information as fact.

Objective

The SOAP notes objective section should be made up of physical findings gathered from the session with your client.

Some examples of SOAP charting for this section include:

• Vital signs
• Relevant medical records or information from from other specialists
• The client’s appearance, behavior, and mood in session

Note: This section should consist of factual information that you observe and not include anything the patient has told you.

Assessment

The assessment section combines all the information gathered from the subjective and objective sections. It’s where you describe what you think is going on with the patient.

You can include your impressions and your interpretation of all of the above information, and also draw from any clinical professional knowledge or DSM-5 criteria/therapeutic models to arrive at a diagnosis (or list of possible diagnoses).

Plan

The last section of your SOAP note should outline your plan for next steps to treat the patient, including short- and long-term goals for your patient. Be specific about what you plan to work on in the next session or in general and your expectations for the duration of treatment.

SOAP note example for speech-language pathologists (SLPs)

Speech-language pathologists (SLPs) also need to know how to write SOAP notes, as SLPs use the SOAP format to capture clinical information about client visits, current assessments, and outcomes.

Here’s sample SOAP charting copy an SLP might use for a SOAP note:

Subjective

The client reports increased vocal demands since the last meeting due to additional meetings at work. She notes her colleagues commented “Your voice is back!” after her last work presentation, but that she still experiences intermittent vocal fatigue during social events. She reports she has been incorporating her semi occluded vocal tract straw (SOVT) routine three times a day for five minutes.

Objective

Led the client through SOVT exercises with a straw in water. Client independently achieved optimal voicing in 5/5 opportunities. Introduced conversational training therapy (CTT) where client differentiated between her “husky” voice and her “presenter” voice in 5/5 opportunities. Practiced functional phrases where client achieved “presenter” voice in 8/10 opportunities with moderate visual cues. The client’s vocal effort using CTT was 4/10.

Assessment

The client met goals of optimal voicing to meet vocational demands, as evidenced by an improvement from vocal effort of 7/10 (“somewhat hard”) to 4/10 (“somewhat easy”). She is pressing toward carryover of SOVT strategies to meet social demands.

Plan

Continue the current plan of care. Target optimal voicing in functional environments with CTT techniques. Introduce additional compensatory strategies to manage vocal load across vocational and social settings.

Remember, SOAP notes are meant to document your findings in a way that’s easy to record and refer back to. Consequently, you should use the format that makes the most sense for your practice.

SOAP Note Exercise

Sources

• Excelsior Online Writing Lab. (n.d.). SOAP notes. Excelsior University.
• SimplePractice. (n.d.). How to write SOAP notes. (with examples).