SOAP NOTES

Overview

Progress notes provide an “organized method of planning, giving, evaluating, and recording rendered client services. A viable method of record keeping is SOAP noting.  SOAP is an acronym for subjective (S), objective (O), assessment (A), Plan (P), with each letter representing one of the sections of the case notes, (Cameron, et al, 2002, p. 286).”  Most agencies also have a deadline regarding when documents must be completed and entered into the client’s file.  Progress notes are usually required within 24-48 hours after as session.  Widely utilized in medical settings, it is also common within the counseling field.

Problem Solving Process

A textbook of mine describes the process of clinical case formulation defining it as: “a conceptual scheme that organizes, explains, or makes sense of large amounts of data and influences the treatment decisions, (Ingram, 2012, p. 3).”  Essentially, this process involves four basic steps: (1) identifying the problem, (2) seeing explanations for them, (3) plan implementations, (4), defining goals, (Ingram, 2012).

  1. GATHERING DATA:  includes subjective and objective data, it is free of assumption, interpretation and/or diagnosis (Ingram, 2012).
  2. DEFINING THE PROBLEM:  stated in simple terms, the problem should be defined as solvable targets for treatment.  It should be comprehensive and complete, reflecting client’s values & not the counselors (Ingram, 2012).
  3. GOALS & OUTCOMES:  There should be a logical relationship between the problems and goals.  They should be realistic, attainable, and testable. Ingram, (2012) describes core clinical hypotheses as useful in these cases and defines them as follows: “a single explanatory idea that helps to structure data about a given client in a way that leads to be better understanding, decision making, and treatment choice, (p. 11).”  
  4. TREATMENT PLAN: includes a description of interventions used to address the client’s problems.  Includes process goals and outcome goals.

Components of the SOAP NOTE

Subjective vs. Objective

Ingram (2012), provides a clear differentiation between subjective and objective data in the folloiwng statement: “What the client ells you goes in [SUBJECTIVE DATA}…how the client tells it goes in [OBJECTIVE DATA], (p. 83).” In other words, the subjective section provides the client’s story in their own words.  The objective data contains observations on how the client tells the story.

(S) Subjective

The purpose of subjective data is to provide a place where the client’ own story can be told.  For this reason, it contains information from the client and the client’s family.  “Without losing accuracy, the entry should be as brief and concise as possible; the client’s perceptions of the problem(s) should be immediately clear to an outside reader, (Cameron, 2002, p. 287).”  Quotations should be kept to a minimum, however important statements pertaining to thoughts such as SI and/or HI, for example should be included.

What client tells you.
What significant others tell you.

(O) Objective

The objective data includes clinical observations, medical records, and the therapist’s impressions.  It excludes case formulation and information pertaining to either the client or family members’ verbal reports.  Objective information should be factual, “written in quantifiable terms – that which can be seen heard smelled, counted, or measured.”  Objective information included can come either from outsider records or the counselor’s observations.  Include information which is precise and descriptive, (i.e. “As evidenced by”).  Words with negative judgments that are open to interpretation should be excluded.   During my practicum class, the instructor required us to include the following: (1) general, (2) speech, (30 psychomotor, (4) mood, (5) affect, (6) thought, (7) insight & judgment, (8) impulse control.

factual information
counselor observations
Information from outside records

(A) Assessment

This section provides an overview of the client’s clinical judgment.  It draws on information from the subjective and objective sections.  It often lists client’s symptoms, diagnoses, and clinical impression.  Cameron, et al, (2002) notes: “the assessment portion of the SOAP notes is the most likely section to be read by others, such as outside reviewers auditing records, (p. 289).”

Summary of counselor’s clinical judgment.
Synthesis of information from subjective & objective sections.

(P) Plan.

Consisting of the plan and prognosis, information here can include a list of future interventions, appointments, treatment progress, and/or psychoeducation.  “the prognosis is a forecast of the probable gains to be made by the client given the diagnosis, the client’s personal resources, and motivation to change, (Cameron, et al, 2002, p. 289).”

Plans for therapy
Overview of treatment plan
Description of client’s prognosis.

An Example of a SOAP NOTE…

This example comes from my practicum class in which I recorded a series of sessions with an individual who was “playing the part” of a character.  Therefore, it does not pertain to an actual client, and is a byproduct of a hypothetical exercise.    Additionally, since it is important to keep in mind, this was my “first” effort at every doing a progress note, (therefore its far from perfect)… 🙂

untitled

POMR – An Alternative to SOAP

Cameron, et al, (2002) also discuss an alternative to the SOAP Format. POMR is an acronym which stands for “Problem-Oriented Medical Record.  It begins with a review of the clinical assessment and continues with a list of problems derived from this history.  It concludes with a treatment plan and progress note.  To read more about this document click here.  It is utilized commonly within the health care field it contains four components:

  1. Data Base – History

  2. Physical Exam and Laboratory Data

  3. Complete Problem List

  4. Initial Plans

  5. Daily Progress Note

  6. Final Progress Note or Discharge Summary

Resources & References

Template of Information to Include in SOAP Note…

Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of Counseling and Development: JCD, 80(3), 286-291
Ingram, B.L. (2012). Clinical Case Foundations: Matching the Integrate Treatment Plan to the Client. (2nd. Ed.). Hoboken, NJ: Wiley.

Share This: