The Subjective, Objective, Assessment and Plan (SOAP) note is an acronym representing a widely used method of documentation for healthcare providers. The SOAP note is a way for healthcare workers to document in a structured and organized way.
This widely adopted structural SOAP note serves to remind clinicians of specific tasks while providing a framework for evaluating information. It also provides a cognitive framework for clinical reasoning. The SOAP note helps guide healthcare workers to use their clinical reasoning to assess, diagnose, and treat a patient based on the information provided by them. SOAP notes are an essential piece of information about the health status of the patient as well as a communication document between health professionals. The structure of documentation is a checklist that serves as a cognitive aid and a potential index to retrieve information for learning from the record.
S (Subjective):
Use this section to document how the client did today and to describe impressions of client behavior and participation in the session. Use quotes when possible. Add any comments from the client/parent/caregiver about progress, confusion or general education and/or medical issues (e.g. not feeling well this past week due to the flu.) Comment on anything relevant that has happened to the client since the last session. Comment on completion of homework and any problems and/or insights. Add any insights or other comments the client made throughout the session. For example, after explaining the instructions again this week, the client said, “Oh, now I get it.” Be sure to use objective language and comment only on what you observed. Do not comment on who came with the client or what time they arrive unless it’s relevant to your intervention plan. Write this section in past tense.
O (Objective):
This section is for measurable information. Use this section to state the objective and report your data. Qualitative and quantitative treatment data. Probe and treatment data. It should be easily readable. You can create a data table or use bullets and include scores from the current session and the previous session so that you can see changes. Keep the data brief and only report data relevant to your objectives. Assessment results are included in this section. Remember, data can be numerical or narrative. You may also write a brief description of the activities here. Write this section in past tense. Don't forget qualitative data goes here too!
A (Assessment):
Use this section to interpret and analyze the data reported above. Questions to address in this section include: Have there been changes since the previous session? What was different about today’s session? Why is the client (not) achieving 100% accuracy? Why types of cues were effective? Not effective? Was my feedback useful to elicit correct productions? What are the barriers to the client achieving mastery? This section can be written in present or past tense.
P (Plan):
This section includes what you will do in the next session and what changes you may make in what you will do as a clinician. Specifically state objectives for the next session. Write this section in the future tense.
*SOAP notes are always written in third person (no "I, we, me") and are focused on the client, not the clinician’s performance during the session
How to make writing SOAP notes concise and not too time consuming:
Pitfall: Students spend too much time writing these SOAPs and trying to include too many direct quotes
Pitfall: Students don't go back and look at examples of past SOAPs to see what type of info to include
What goes in each section of SOAP notes?
Pitfall: Students tend to put qualitative data in the S or A section instead of the O section
Pitfall: P sections don't have to be a full on lesson plan - just a quick note about what you're going to do next
What makes a good lesson plan?
The goals and objectives guide the session (not the activities!)
For every activity, it must be clear what goal it aligns with and is addressing
Without goals there is no session
Opportunities for engagement and building on motivations and interests of the client
Some structure, some flexibility
Multiple learning opportunities
Scaffolding built in
Data collection methods mapped out and ability to take data on levels of support provided (not just correct/incorrect)
Time at the beginning for check in and introduction
Time at the end for wrap up and kudos
Common Pitfalls:
Planning how long things will take. It is okay to plan 3 coree activities and 2 spill over that will be used only if needed
Grammatical and spelling errors - watch this as the forms will not take care of it for you!