SOAP notes counseling

  • Tuesday, April 9, 2019
SOAP notes counseling, therapy notes, SOAP, SOAP note, SOAP note format, SOAP notes mental health, soap progress notes, soap notes counseling, progress notes, progress note vs psychotherapy note, tips for writing progress notes, tips for writing SOAP notes

Of all the things that therapists have to do, SOAP notes and note-taking is probably one of the most tedious and confusing things we do. It is also an absolute necessity.

SOAP notes are the way you document that a client participated in and completed a session with you. Depending on the billing process you have, a completed therapy note may also be the way a claim is generated. Documentation also demonstrates your competency and shows how a client’s needs have been addressed.

Before talking about therapy notes such as SOAP notes, know this: not all therapy notes are created equal. There are progress notes and there are psychotherapy notes. Most therapists keep some form of therapy notes but they are very different and treated differently under HIPAA.

  • Psychotherapy notes are detailed, private notes that a therapist may keep. These notes may contain observations, impressions and other details of the session. These notes do not follow a standard format and are stored separately. These types of notes have special protection under HIPAA and are NOT contained in the client’s record.

     

  • Progress notes are part of the client’s record that provide details about the client such as diagnosis and assessment, symptoms, treatment and progress towards treatment goals. They follow a standard format (e.g., SOAP, BIRP, etc.) and ARE included as part of the client’s record.

 

SOAP NOTE 101

Most mental health clinicians utilize a format known as SOAP notes. SOAP is an acronym that stands for:

            S – Subjective

            O – Objective

            A – Assessment

            P – Plan

A SOAP note is a progress note that contains specific information in a specific format that allows the reader to gather information about each aspect of the session.

Now, to be honest, most clinicians weren’t “trained” on SOAP notes as part of graduate training. Chances are you picked up some therapy note-taking skills along the way. Some of you might be doing long, narrative notes that contain way more information than is appropriate for a progress note. (See progress vs. psychotherapy note descriptions above) So, let’s break down a SOAP note and take a closer look at it contains.

Subjective This section contains information relevant to what the client reveals in the session. This may be the client’s chief complaint, presenting problem and any relevant information. This information may include direct quotes from the client. This section also includes things discussed during session. For example, you may have discussed your client’s complaint of not sleeping well and sleep hygiene. Use words like “Discussed” or “talked about” or “reviewed” when describing things talked about in session.

Objective – The objective section contains factual information. Such objective details may include things like a diagnosis, vital signs or symptoms, the client’s appearance, orientation, behaviors, mood or affect. For example, client is oriented x4 (person, place, time, situation), client appears disheveled.

Assessment This section is the place where you, as the clinician, document your impressions and interpretation of the objective and subjective information. This documentation may include clinical impressions related to factors such as mood, orientation, risk of harm as well as assessment of progress towards goals. Here you want to describe your impressions. For example, client appears to understand the new goal.

Plan – This section documents what the next step is for the client. What do you, as the clinician, plan to do with the client at the next session? This is also the place to document things like the anticipated frequency and duration of therapy, short and long term goals as well as any new goals. Be sure to note any homework assignments or tasks you’ve given your client.

It sounds like an easy format to follow but it does take some practice.

Tips for Writing Progress Notes

As with any clinical documentation, you want to be sure you are including pertinent information. You also want to avoid errors that can at best be annoying and at worst, place you in legal jeopardy.

First, breathe. No therapy note is 100% perfect. Depending on who looks at it, there will always be something that could be written more clearly, more detailed, less detailed…something. The key is to write clear, thorough notes in a timely and consistent manner.

Here are some tips for writing solid progress notes:

  • Write your note as if you were going to have to defend its contents.
  • Use clear and concise language. Avoid using slang, poor grammar or odd abbreviations.
  • Pay attention to spelling, person and tense.
  • When quoting a client, be sure to place the exact words in quotation marks.
  • Keep your notes short and to-the-point. Be clear and complete. Avoid expanding beyond what is required for each section.
  • Be mindful of correct dates, times, spelling of names.
  • Avoid making subjective statements that cannot be substantiated. When making subjective statements, include pertinent evidence. For example, client appears anxious as evidenced by wringing his hands, excessive tapping of fingers, hyperventilation.
  • Never, ever alter a record using any type of correction eraser/tape/fluid/mark outs/scratch outs.

Errors happen. Even the most careful note writer will make mistakes. If you find an error, resist the urge to just scratch it out or otherwise alter the record. Omissions, deletions and altered records create suspicion about its validity. The best way to correct an error is to use an accepted procedure for error correction. Here’s an example of one such procedure:

If you find an error, use a single strike-through (abc), write “error” next to it, and initial the error. Write in the correction and initial the correction. This way, the reader can see the original error, see the corrected information and see who made the correction. A word of caution: you want to be the one to correct your own records.

With a little practice, you can be a skilled progress note writer.

TheraPlatform offers progress note templates that take all the guesswork out of remembering all the details of SOAP. Choose from an entire library of templates that you can use to streamline your documentation process. You’ll be able to efficiently and confidently complete your notes which means less time spent stressing over documentation. And all it takes is a little SOAP.  

Resources
informed consent forms, informed consent in counseling, therapy consent forms, client consent form, consent to treat mental health,consent forms templates, consent forms private practice, consent for teletherapy, consent form example, consent form for telehealth, consent form for telemental health, consent form for telespeech, consent form for telepractice, consent form for telepschyology, consent forms for SLPs, consent forms speech therapy, consent forms OT, consent for PT, consent form physical therapy, consent form occupational therapy, consent form counseling, teletherapy, telemental health, telepractice, consent form social worker, informed consent, consent to treat mental health, telehealth mental health, telehealth counseling

3/11/2019

Consent Forms and Telemental Health – The Struggle is Real

Informed Consent Forms for mental health providers and therapists providing telehealth services such as online therapy can be a real struggle. Here are tips for informed consent forms.

superbill, superbill template, how to create superbill; what superbill should include, superbill generator, superbill software, speech therapy superbill template, physical therapy superbill,occupational therapy superbill therapy, superbill insurance,superbill reimbursement, patient superbill form, superbill example,psychotherapy superbill template, superbill template mental health

2/21/2019

The Superbill: What It Is and Why You Need It

A superbill is a document that contains all of the information necessary for an insurance to make a decision on reimbursement for health expenses incurred by a client. What’s in the superbill and why you need one?

Start 30-day Free Trial
Resources
Updates
Teletherapy
Law
Telepractice
Marketing
Getting Started
Press
Behavioral Therapy
Insurance
Case Studies


Latest Posts

  • Starting Private Practice

    Tuesday, September 17, 2019

    Starting a private practice in therapy or counseling requires not only clinicial experience but essential tools that will help therapists to start a private practice and run it smoothly as well.

  • Text appointment reminders

    Tuesday, September 3, 2019

    Text appointment reminders and a few new improvements are now available in TheraPlatform!! Text appointment reminders are a great way of reducing missed appointments in your private practice and keeping a steady flow of income.

  • Art Therapy Activities

    Tuesday, August 13, 2019

    Art therapy activities offer many outstanding benefits with helping clients obtain their treatment goals. For children it can be difficult for them to verbalize their feelings; however, they can illustrate them clearly through their art therapy activities. This assists their therapists to identify deeper issues and help the children work through them. Here a few ideas of art therapy activities that can be utilized when working with both adults and children.

This website uses cookies to ensure you get the best experience on our website.

Learn More