SOAP Note Sections: S, O, A, & P
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This section explains the four major sections of a SOAP note, Subjective, Objective, Assessment, and Plan.
Subjective
The subjective section should describe the practitioner’s impressions of client/patient and information reported about or by the client/patient.
Sample Language:
“Client appropriately interacted with clinician throughout the session.”
“Clinician informed unit nurse of client’s c/o pain in lower back.”
The subjective section can also be an area where the client’s own voice comes through. Depending on the field in which you are writing notes, you may want to include paraphrased information on what the client said, using quotes for pertinent language, client’s stated progress and link to previous notes’ goals, or what the client reported to be relevant for this session.
Sample language:
“Cl mentioned that her brother had called her an ‘egomaniac’ and ‘stupid’ this week. Client reported that she’d ‘had enough’ of her brother’s taunts and that she couldn’t understand why he had to treat her so poorly.”
Note that the above example only includes key words and phrases from the client, rather than extended passages of client language.
Possible details to include: level of attention, level of engagement, family member’s or other healthcare provider’s report to practitioner regarding the client/patient, client quotes, client’s report of anything practitioner feels is significant.
Objective
The objective section should include all pertinent measurable information taken during the interaction. Think of this section as consisting of information that anyone observing the interaction with the patient or client could agree to have happened.
Sample Language:
“Client obtained 70% accuracy on short term goal #1.”
"Near the end of the session, the client began to cry when she discussed not being able to find a new job after 4 months of searching."
Possible details to include: measurements taken, test results, data taken on therapy goals, quantifiable observations
Assessment
The assessment section should include the practitioner’s analysis of the session. If the practitioner has had previous interactions with the client/patient, the section can include an analysis of the interaction being documented compared to previous interactions.
As with all sections of SOAP notes, the Assessment section should be written very carefully. Although this is an area for the clinician to include his/her professional impressions, no statements should be written that cannot be verified with evidence. It is important to keep in mind that there are numerous individuals who will have access to these notes, so the assessment of the patient or client should be based on assessments or observed behavior.
Sample Language:
“Performance on problem solving tasks is a relative strength.”
“Client states that he has withdrawn from social activities with peers. He has expressed having reduced energy, diminished sleep (typically only getting about 4 hours a night), and pessimistic thoughts. Client may be experiencing mild depression. No other symptoms were reported or observed.”
Possible details to include: Treatment efficacy or inefficacy, analysis of a specific detail that was unusual or unexpected, methods that proved particularly motivating or successful for the patient/client and those that did not, information from the subjective and objective section to help strengthen clinical hypotheses
Plan
The plan section should outline the course of treatment for a future or future interactions.
Sample Language:
“Continue with POC.” (plan of care)
“Prepare bill and send to client’s spouse.”
“Modify short term goal 2B to reflect client’s present level of ability.”
Possible details to include: goals and objectives for the clinician between this session and the next, goals and objectives for the patient or client between this session and the next, changes in treatment, changes in therapy goals, administrative business, referrals, topics to be discussed, interventions or treatments to be implemented