When preparing notes for a patient’s chart, it’s imperative to provide information in a clear, concise format. These notes will prove to be invaluable for healthcare professionals and help insurers justify procedures. And while any notes need to be thorough enough to fully cover the patient’s visit and condition, they also need to be brief enough to be quickly understood for faster treatment.
The SOAP format — Subjective, Objective, Assessment and Plan — is an ideal standard to follow for providing the necessary information. But are you taking full advantage of how you can use this format? Let’s break it down by category to examine how your SOAP notes can be as effective as possible.
This category covers all historical information the patient expresses about their symptoms. It is also an appropriate place to indicate any comments made by the patient as well as their family members or caretakers. However, it’s vital that the patient’s own words are recorded, as opposed to being paraphrased. This provides the clearest insight into their condition.
To cover these conditions systematically and to ensure you don’t miss anything important, a good rule of thumb is to follow the OLDCHARTS acronym. This stands for:
Onset — to determine when symptoms first started
Location — the primary location of pain or discomfort
Duration — the length of time the patient has suffered symptoms
CHaracter — types of pain, such as aching or stabbing
Alleviating or Aggravating Factors — any actions or interactions that reduce or increase the severity of symptoms
Radiation — indicating if the pain radiates to other locations
Temporal Pattern — whether the pain appears in a pattern, such as evenings or after meals
Symptoms Associated — any symptoms aside from the main complaint
By following this guideline, your notes on the subjective elements of the patient’s report will be concise, yet thorough enough to fully educate anyone reviewing the report.
The objective portion of your note covers the functioning of the body, including the area of neurological functioning called the Mental Status Exam. What did you observe about this client? These are written as factual notations. In this section, only raw data concerning functioning should be documented, not your findings or diagnoses. All measurable data, such as test scores, vital signs and observations during the patient’s visit should be recorded. A brief description of the client’s mental status includes observations about the cognitive, psychological and emotional functioning of the client.
With a limited window for examination, it’s important to closely observe the patient for anything that can complement or contradict information provided in the subjective section of these notes.
This section of your SOAP note is for a diagnosis of the patient’s mental health issues. This can be as simple as a single obvious diagnosis, or it could cover a range of problems they’re experiencing.
Depending on what information has been derived from any lab tests or rating scales, a definitive diagnosis may not yet be viable, so provide your analysis based on the most up-to-date information available.
This final element of your note encompasses the course of treatment planned to address the specific deficits described in the assessment. The plan should set a clear roadmap for the patient and/or another clinician to be able to continue the treatment if needed. The plan should always be related to the assessment, and on the following visit, progress with the plan can be appropriately assessed.
The Formula for Success
Following the SOAP style ensures that you consistently document the patient’s current condition and progress in treatment. Good notes provide documentation that the therapist is following acceptable standards of care, utilizing appropriate interventions, describing the results of these interventions and documenting the disposition of the case.