Embedded Files
Providers are expected to start the note for each patient at the time of the appointment and document 100% of sessions 24-72 hours after the session is held. Documentation in SOAP note form is required as it ensures high-quality progress notes, conciseness, and relevance that demonstrates clinical reasoning.
The purpose of SOAP notes are:
To track progress. SOAP notes are vital for documenting your patient's progress and whether they are making improvements with the current treatment plan administered. If the patient is transferred or referred out, other providers should be able to assess the SOAP note(s) and identify and evaluate changes.
To foster strong communication. SOAP notes concisely summarize behavioral health clinical insights, screenings, and assessments. All information is up to date and recorded with high accuracy to ensure that essential details are effectively communicated. Beware of the "Copy and Paste" technique. It is useful in some places BUT not others.
To fulfill legal obligations. In the case of malpractice, or if a patient's health condition becomes involved with legal issues, SOAP notes are an excellent way to protect you and Sensible Care, as it provides primary evidence with clinical reasoning. These can be used in legal cases and ensure that you remain and uphold compliance to avoid potentially costly consequences.
For insurance purposes. Accurate and completed SOAP notes are required to receive reimbursement from 3rd party payers.
For military related purposes. SOAP notes help to effectively and efficiently treat and share pertinent information about active duty military personnel while accommodating the military treatment facility's (MTFs) unique and strenuous administrative requirements.
Psychotherapy notes document and/or analyze conversation content during a private or group counseling session and is separate from the rest of the client records. These notes include initial impressions, hypotheses, observations, and thoughts or feelings.
These notes are private to the individual provider and are NEVER stored within Practice Fusion. Neither the patient nor any other third parties have the right to see these notes without severe legal action.
These can be hand-written and stored in a locked filing cabinet/safe or digitally on a Sensible Care-issued computer or Google Drive. When a medical records request is received, only SOAP notes and what is present in the patient’s chart are shared.
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