Note: Post is published and still under development as of 20211010
Additional links to reference:
https://www.icanotes.com/2018/04/25/tips-for-writing-better-mental-health-soap-notes/
A SOAP (Subjective, Objective, Assessment, Progress/Plan) Note is a document used by a clinician (Licensed Clinical Social Worker or Associate Social Worker) while engaging with a client. The outcome is a written record which can be used for maintaining an historical record, analyzing trends, efficacy of treatment/interventions, justification for escalation, and so forth.
Each clinician (Medical Doctor, Nurse, Social Worker) may have a different area of focus, detail and structure within their SOAP Notes. For me (Social Worker), I’m going to start very simple, and customize as needed. While I prefer paper to capture information, my plan is to create an electronic version of the SOAP Note in Microsoft Excel. That way, I can search for keywords, etc.
This website gave a good overview for SOAP Notes for Social Workers. Here is my interpretation of the four (4) key areas to observe and capture within each client interaction:
Subjective Data
Objectively, while withholding any judgment, recording (clinically important) statements made by client (person/s in front of me) during session. The verbal statements are received as input and may include feelings, thoughts, actions, treatment objectives, concerns. Typically, this would be something recent and top-of-mind, but also could be something from the past. A good example is a client who says, “I had a good day”. In this section, I’m not making meaning of the phrase, but it’s worthwhile to make note.
Objective Data
What I’m observing as a physical manifestation. What I’m clinically measuring using a tool (FIT, Mini Mental-Health, etc). In this section, I’m noting my observations, but I’m not making meaning of or interpreting it. The physical observation can inform the verbal input. For example, if the body language is tense with rapid breathing and red-faced, then that informs the verbal statement within the prior subjective section. This section is classic grooming observations: clothing presentation; hair combed/brushed; shaven; general hygiene. Observing items within the living space is important to note – carpet cleaned; hoarding; trash piles away from garbage can, etc. In this section, I’m also observing “how” someone is relaying similar/identical information that they may have done in the past, noting the information is relayed with different intensity, for example. If within the session I captured an assessment (FIT, Mini Health Status Exam), then I have the raw data and can interpret it within another section.
Assessment
Outcome of reviewing the above Subjective and Objective notes, where I’m synthesizing, assessing or understanding a through line or possible hypothesis of the data — making meaning of it all. I can also be reflecting back on prior sessions and seeing patterns of change, ability for client recall, what’s working, what’s not working, etc. Seeing how family dynamics over the course are impacting client progress, etc.
Progress and/or Plan
This is my opportunity to step back for a moment and see things at a higher level. How is the client’s progress being evaluated. Have the client’s symptoms changed – decreased increased, plateaued. What specific changes has the client made. What actions has the client completed that maybe a first. What are the next actions regarding treatment (talk therapy, actions, meds, etc).
Additional items to include in a SOAP aka Progress Note
-What is the specific and tangible goal we’re heading to, so we have a point-of-reference when we arrive somewhere.
-Is there a RISK to self, to others, from others. If that happens, what is the plan.
-Each session has a date, and a start and finish time. Everything is documented on the progress note, including any lateness or shortened sessions.
-What is the progress made towards a discharge plan
-What community support services does the client need and how to integrate this into treatment plan.
-What is the plan and scheduled day/time for next session.
-What’s getting in the way of client’s goals or progress – what are the stressors.