Lecture 2: Writing SOAP Notes

Learning Objectives: Hello everyone! Today, we are diving into the art of crafting effective SOAP
notes. By the end of this lesson, you will gain a thorough understanding of the SOAP note structure
and its significance in patient documentation. We will focus on developing your skills in writing clear
and precise subjective and objective observations, ensuring that you can capture and document
patient information accurately. Additionally, you will learn how to analyze the information you have
gathered to formulate well-reasoned assessments and actionable plans. Imagine yourself in a clinical
setting, documenting patient interactions—how can you ensure that your notes are both
comprehensive and concise? We will tackle this challenge together, exploring each section of SOAP
notes and refining your documentation techniques.

To fully grasp the significance of SOAP notes, let’s delve into their origin and purpose.

Introduction
SOAP stands for Subjective, Objective, Assessment, and Plan (in that order). It is a method of note-
taking that allied health professionals use to record and review ongoing patient care. SOAP notes were
introduced in the 1960s by Dr. Lawrence Weed, known for his work in medical record standardization.
His vision was to improve the quality of patient care by creating standard patient documentation
systems and the success of his pioneering is evident in the broad use of SOAP notes in allied health
today. Standardized documentation through SOAP notes is essential for maintaining accurate records,
facilitating effective communication among healthcare teams, ensuring continuity of care, and
meeting legal requirements. It enhances patient safety by providing a comprehensive overview of the
patient's condition and treatment progression over time, thereby improving overall quality of care
and patient outcomes.
1. Techniques of Writing SOAP Notes
Writing SOAP notes effectively involves employing specific techniques to ensure clarity, accuracy,
and completeness in documenting patient encounters across each section—Subjective (S),
Objective (O), Assessment (A), and Plan (P).
➢ Subjective (S): The Subjective part of SOAP notes involves gathering patient-reported
information, symptoms, and medical history. It focuses on what the patient feels and
their personal health background. Effective interviewing techniques are used to
gather comprehensive subjective data, ensuring all relevant details are documented
accurately. This section requires you to skillfully capture patient-reported information
using precise and descriptive language. For instance, instead of simply stating "Patient
complains of chest pain," a more detailed approach would be: "Patient describes a
squeezing sensation in the chest, rated 7/10 in severity, radiating to the left arm,
intensified by effort, and lessened by rest." Effective techniques include active
listening during patient interviews to gather comprehensive details and using open-
ended questions to prompt detailed responses. Providers should aim for concise yet
thorough summaries that convey the context and nuances of symptoms clearly.
Content to avoid:
❖ Do not include statements without supporting facts. Statements such as "Client was
willing to participate” is an opinion until you provide facts to support this observation.
Consider only information that you feel is relevant and statements from the client,
loved ones, or teachers that can be attributed to the client's motivation, awareness,
and willingness to participate.
❖ When making subjective statements, include pertinent evidence. For example: "Client
appears nervous as evidenced by fidgeting of hands, not maintaining eye-contact, and
shortness of breath during our session”
➢ Objective (O): Writing the objective section involves documenting measurable data
obtained from physical examinations, diagnostic tests, and observations using
standardized medical terminology. For example, rather than noting "Vital signs
stable," a more precise entry would be: "Blood pressure 120/80 mmHg, heart rate 80
bpm, and temperature 37°C." Techniques include using descriptive language to
accurately portray clinical findings and avoiding subjective interpretations. Providers
should ensure that each observation is factual, verifiable, and relevant to the patient's
current health status.
Content to include:
• Physical, interpersonal, and psychological observations
• Verbal/non-verbal
• Body posture
• General appearance
• Affect and behavior when discussing certain topics or issues
• Nature of therapeutic relationship
• Client's strengths
• Client's mental status
• Client's ability to participate in the session
• Client's responses to the process
• Written materials such as reports from other providers, psychological tests, or
medical records (if applicable)
Content to avoid:
• General statements without supporting data
• Avoid assumptive statements pertaining to behavior (avoiding statements that
imply assumptions about why a patient acted or behaved in a certain way without
clear evidence or direct observation.)
• Labels (like "difficult patient," "compliant," "non-compliant," "demanding,"
"difficult," or "challenging." These labels can be subjective, vary in interpretation, and
may carry negative connotations that can influence subsequent care decisions or
patient interactions.)
• Personal judgments
• Value-laden language (Language with value judgments or biases)
• Opinionated statements (personal rather than professional opinions)
 • Words/phrases that have negative connotations and/or are open to personal
interpretations (ex: uncooperative, obnoxious, normal, drunk, spoiled)
➢ Assessment (A): The assessment section requires analytical skills to synthesize
subjective and objective data into clinical impressions and differential diagnoses.
Effective writing techniques include logically organizing information and providing
clear explanations of clinical reasoning. For instance, instead of simply stating
"Possible chest infection," a more detailed assessment could be: "Clinical assessment
suggests acute exacerbation of chronic bronchitis; differential diagnoses include
pneumonia and exacerbation of COPD." Providers should justify their assessments
based on the correlation between subjective symptoms and objective findings,
ensuring that the assessment accurately reflects the patient's condition and potential
diagnoses.
Examples of content to include:
• Patient appeared unusually disheveled, exhibited excessive anxiety and worry
toward partner's threat of abandonment and denial of autonomy
• Patient appears to continue experiencing anxiety
• Patient continues to experience family-related stressors
• Patient exhibited signs of moderate depression
• Patient anxiety has increased in severity and appears to meet the criteria for GAD
Content to avoid:
• Do not repeat your previous statements in the S. O. sections. In this section, you
should instead include: progress, regression, or plateau of client progress.
➢ Plan (P): Writing the plan section involves outlining specific interventions, treatments,
and follow-up actions based on the assessment. Techniques include prioritizing
information and ensuring the plan is actionable and comprehensive. For example,
instead of "Prescribe antibiotics," a more detailed plan would be: "Initiate treatment
with oral azithromycin 500 mg daily for 5 days; schedule follow-up appointment in 2
weeks for re-evaluation of symptoms and spirometry testing." Providers should
include specific instructions, such as medication dosages, referral details, and patient
education plans, to guide continuity of care effectively.
Content to include:
• Introduce designated assessments to assess the patient 's focus and
uncontrollability.
 • Focus on patient 's reported symptoms or issues in daily functioning (frequency,
duration, intensity, and type), if applicable.
• Continue to build trust and confidence with the patient to allow space for
exploration of previous events similar to current stressors, and explore those
conclusions.
Examples of content to include:
• " Patient will consult with a licensed nutritionist, in order to create a healthy diet
and lifestyle plan."
• " Patient will begin yoga classes at the local gym."
• " Patient is committed to attending group therapy sessions for eating disorders."
Content to avoid:
• Restating overall treatment plan (as opposed to goals for the next session)
• Unrealistic, immeasurable goals to be accomplished before the patient's next
session

2. Tips For Effective SOAP Notes

Find The Appropriate Time to Write Soap Notes
Avoid: Writing SOAP Notes while you are in the session with a patient. You should take personal
notes for yourself that you can use to help you write SOAP notes.
Avoid: Waiting too long after your session with a patient has ended.
Maintain a professional voice.
Avoid: “The patient had a blast during the group therapy session.”
“Had a blast” is informal and not descriptive.
Use instead: “The patient smiled and laughed during the group therapy session.”
 This statement specifically describes the actions of the patient and maintains a formal voice.
Avoid overly wordy phrasing.
Avoid: “Careful consideration and thought have lead this clinician to conclude that the patient
responds very positively to physical cues.”
This statement is overly wordy and could be simplified to state the main idea in a quicker and
more precise manner.
Use instead: “The patient shows greater success with activates involving physical cueing.”
This statement quickly draws a conclusion that might be helpful for a future practitioner.
Avoid biased overly positive or negative phrasing.
Avoid: “The patient could not even say his own name.”
This statement is judgmental and makes an assumption about the patient’s ability without specific
evidence to substantiate it.
Use instead: “The patient did not verbalize his name after being prompted twice by the clinician,
‘Tell me your name.’”
This statement gives specific information regarding the patient’s behavior under specific
circumstances without being judgmental.
Be specific and concise.
Avoid: “The patient was able to write her name.”
This statement is vague, and it is unnecessary to write “was able to.”
Use instead: “Given a pen, paper, and verbal instructions, the patient wrote her name legibly.”
This statement gives specific details regarding the circumstances of the observation and is not
overly wordy.
Avoid overly subjective statement without evidence.
Avoid: “patient was very frustrated”
Words like “very” and “a lot” do not help the reader understand behaviors of the patient.
Use instead: “patient grimaced and sighed repeatedly during the latter half of the therapy
session”
This statement gives the reader a clear description of the patient’s behaviors without making
assumptions about the patient’s internal state that lack specific support.
Avoid pronoun confusion.
Avoid: “The clinician instructed the patient to state her name.”
It is unclear whose name the patient was asked to say.
Use instead: “The clinician instructed the patient to state the patient’s first name.“
A commonly used term in some fields that can help to avoid confusion is “this clinician.”
 Avoid: “patient stated that his father was in town. He reported that he feels that he frequently
ignores what he says whenever they are together.”
Who is ignoring whom?
Use instead: “patient stated that his father was in town. patient reported that he feels that his
father frequently ignores what the patient says whenever they are together.”
Be accurate but nonjudgmental.
While other healthcare professionals are the primary audience of SOAP notes, be sure that the
SOAP note is written so that it would not be construed as offensive were a family member to read
it.
Avoid: “The patient’s mother, obviously mistaken, claimed that Susie said her first word at three
months of age.”
The wording “obviously mistaken” is overly judgmental and does not add any important
information to the SOAP note.
Use instead: “The patient’s mother reported that Susie said her first word at three months of
age.”
This statement is accurate and nonjudgmental. A healthcare professional familiar with typical
language development would recognize that such an event is implausible.

SOAP Note Example

Patient Full Name: Connor Client

Patient Date of Birth: 2/2/1992
Date of Service: 7/10/2023
Exact start time and end time: 1:33 pm – 2:30 pm: 57 mins
Session Location: 123 Serenity Lane, Miami, FL 33143
Diagnosis: (F32.1) Major depressive disorder, single episode, moderate)

Subjective:
During the session, the patient, Connor, reported a significant improvement in his overall mood
since our last meeting. He has been consistently utilizing coping mechanisms that were
previously discussed and has been making an effort to engage in activities that he once found
enjoyable. He expressed that his depressive symptoms have decreased in both intensity and
frequency. Additionally, Connor mentioned a recent family gathering where he felt more
engaged and connected with his loved ones. This positive experience provided him with a sense
of social support, which he believes contributed to his improved mood. However, Connor
expressed ongoing concerns about his sleep patterns, noting occasional difficulty falling asleep
and early awakenings.
Objective:
Since our last session, Connor does not present a risk to self or others. His affect during the
session was brighter and more animated compared to prior meetings. He actively participated
in the session, showing improved eye contact and verbal expression. His body language
suggested a decrease in overall tension compared to previous sessions. Connor's energy levels
have improved, and he reported engaging in physical activities such as walking and jogging on
a regular basis. His mood was calm, and his affect was appropriate for the course of the session.

Assessment:
Based on today's session, it is clear that Connor has made significant progress in managing his
depressive symptoms. The combination of psychoeducation on coping strategies and increased
engagement in pleasurable activities seems to be contributing positively to his overall well-
being. His affect, mood, and verbal expression have all improved, indicating a positive response
to therapy. However, Connor's ongoing concerns regarding his sleep patterns warrant further
exploration. His difficulty falling asleep and early morning awakenings may indicate the
presence of underlying stressors, which need to be identified and addressed.

Plan:
Moving forward, we will continue to reinforce and build upon effective coping strategies, such
as mindfulness and behavioral activation. Additional attention will be given to Connor's sleep
disturbances. We will explore potential triggers and stressors contributing to these issues and
provide psychoeducation on sleep hygiene and relaxation techniques. The development of
additional relaxation techniques to address his sleep concerns will also be considered. Connor's
progress thus far is promising, and continued therapy sessions will aim to further improve his
mood, manage his depressive symptoms, and address his sleep concerns.

This document is intended for educational purposes only. Examples are for purposes of
illustration only. It is designed to facilitate compliance with payer requirements and applicable
law, but please note that the applicable laws and requirements vary from payer to payer and
state to state. Please check with your legal counsel or state licensing board for specific
requirements.

Source: https://headway.co/resources/soap-note