When it comes to writing mental health progress notes, there’s no shortage of formats to choose from. Although the alphabet soup of progress note acronyms is extensive, the SOAP framework is a standout. This user-friendly format helps you efficiently write progress notes that are clear, concise, and easy to understand.
Quality progress notes are a win for both you and your clients. Good notes make it easier for you to track each client’s progress over time and plan for future interventions, resulting in higher-quality care. Robust documentation also reduces the likelihood that payment from insurers will be delayed or denied and can make an audit much less stressful. In this post, we’ll explore the mechanics of writing progress notes using the SOAP format and share four tips for taking your progress notes to the next level.
The SOAP format is one of the most commonly used methods for writing mental health progress notes. This easy-to-use framework helps you capture the most critical information from a session using a clear, concise structure.
SOAP is an acronym that stands for Subjective, Objective, Assessment, Plan. Let’s unpack each section of the note.
This section is dedicated to the qualitative information you gather from the client’s point of view. Examples of subjective data include their perception of progress, issues they continue to struggle with, gains they feel good about, and any goals they have for future sessions. Opening up the session by asking how things are going can yield a rich amount of subjective data.
While your client is the primary source of subjective data, you’re the main source of objective data. This section is where you’ll spell out what happened during the session. Include data like the type of interventions you used, the client’s reactions, and the results you achieved. Observations you made about the client’s demeanor, response to the interventions and attitude belong here too.
The assessment section is where you synthesize the information you’ve recorded in the subjective and objective sections and document your clinical impressions. You’ll offer your professional opinion on relevant factors like the client’s mood and their progress towards their treatment goals. If you’ve administered any clinical measure like a rating scale or inventory, add the results here also.
With your information gathered and assessments made, it’s time to plan for what’s next. What will be the goal for the next session? Did you give the client any homework to complete before you meet again? What’s the anticipated frequency of therapy sessions moving forward? What are the client’s current near and long-term goals? Did the session reveal a need for any other goals?
Writing mental health progress notes using the SOAP format is pretty straightforward. Writing good ones, however, takes a bit of practice. Here are a few pointers for writing better SOAP notes.
When you’re in a session with a client, limit your note-taking to jotting bullet points and other memory aids you’ll use to write your progress notes later. Give your client your full attention and focus 100% on what they’re saying with their words and body language. Focusing on the client will allow you to gain data you might miss otherwise.
Templates can save time when you’re writing progress notes. Since they provide the SOAP note structure in a ready-made format, a template allows you to focus on the content rather than the structure. If you’re using a practice management system like MyClientsPlus, you can access easy-to-use templates right from your software.
It’s possible to pack a lot of information into a small number of words. Get into the habit of cutting out unnecessary verbiage and lengthy descriptions. Staying succinct saves time now as you write and time later as the notes are read.
Notes must be detailed enough to provide sufficient information and aid understanding for you and other professionals who need access to them now or in the future. They will become an important part of your client’s mental healthcare record. Avoid slang, jargon, or unusual abbreviations that could confuse readers not familiar with your way of writing.
The only person who should be identified in your progress by name is your client. You should anonymize friends, partners, and other family members to protect their privacy. A first initial or nickname you’ve created works well.
The SOAP note format is one of the most popular for writing mental health progress notes, and for good reason. It offers a simple, straightforward framework for recording valuable information from a therapy session. And because it allows you to follow a template, it will enable you to focus on the data efficiently.
Read The Comprehensive Guide to Effective Therapy Progress Notes to learn more about creating treatment plans and progress notes.