Writing concise mental health notes can be challenging, which is why many healthcare providers use templates like SOAP. SOAP notes can make note writing much more organized and consistent across specialties — if you know how to write them effectively. Whether you're experienced or new to note writing, part of knowing how to write SOAP notes is understanding the common mistakes and how to avoid them.
Learn how to avoid common SOAP note mistakes and what SOAP notes might look like in the behavioral health industry. Walk away with a slew of tips for writing better SOAP notes and the best way to reduce the burden of tedious documentation.
Table of Contents
- What Are SOAP Notes?
- Overcoming Common SOAP Note Mistakes
- SOAP Note Examples
- Additional Quick Tips for Writing Better SOAP Notes
- Pro Tip: Reduce Your Documentation Burden
- Try ICANotes for Free
What Are SOAP Notes?
SOAP notes are a concise and standard way of writing notes healthcare providers use to document patients' progress and treatments. When Lawrence Weed theorized this template for writing notes in the 1960s, it was primarily used in the medical field. Now, SOAP notes are used in all healthcare specialties as a way to organize and efficiently communicate patient and client notes. Because patients often visit different healthcare providers for different services, SOAP notes make it simple to share patient information between providers to ensure everyone is on the same page.
SOAP is an acronym that stands for Subjective, Objective, Assessment and Plan. Each section should contain specific information that will be used in the overall treatment plan for a client.
The subjective section of SOAP notes is where providers should record information that the client expresses about their symptoms and experiences. This section is also where the input of the client's family should be recorded, as they can provide additional insight regarding the client's condition and progress. Recording direct quotes will be most beneficial in gaining insight into the client's perceptions about their mood, goals and needs.
Detail is important when it comes to noting a client's symptoms or feelings. Gain valuable insight by asking your client to elaborate on the eight elements of their present symptoms, which are:
- Location or radiation
- Character or types of concerns
- Aggravating factors
- Relieving or alleviating factors
- Timing or temporal patterns
- Severity and symptoms
In addition to present symptoms, the subjective section is also a good place to keep track of the client's medical and family history.
Your objective notes should be strictly facts and raw observations. Record what you notice about the patient without including opinions or diagnoses. This section is where you should record test scores or other measurable data.
The objective section is also where you should separate signs from symptoms. Signs are observable, whereas symptoms are what a client claims to experience. When objectively observing a client, look for signs that might confirm or contradict the symptoms you recorded in the previous section.
In the assessment section, you will interpret and analyze the combined information from the subjective and objective sections to determine a diagnosis. Arriving at a diagnosis can take several sessions, so you may create a list of possible diagnoses in early sessions and narrow the possibilities as you gain more information. After reoccurring appointments, this section will be where you evaluate the client's progress in your treatment plans so you can make adjustments as needed.
Your plan is where all the previous sections come together. Note the next steps in your client's treatment plan, any "homework" they should complete before returning, when they have another appointment and the short and long-term goals of the plan. The treatment plan you create should include actionable items to help guide the client toward a solution. Remember that your plan is subject to change, and these changes should be recorded in your SOAP notes.
Overcoming Common SOAP Note Mistakes
SOAP notes for counseling can make writing mental health notes far more efficient. However, there are some common mistakes providers make when using the SOAP template. Luckily, if you know what to watch out for, the following mistakes are easy to avoid:
- Don't include unsourced opinions: When documenting your client's opinions of their conditions in the subjective section, be sure to provide attributions to the statements. Whether the client or a family member made the statement, it's crucial to include the source of the opinion. Doing so will help prove that, while you considered the client's opinions, your overall assessment was based on the factual information you gathered during your sessions with the client.
- Don't make general statements without supporting data: The objective section of your SOAP notes is for hard facts and specific observations. General statements can often lean toward being impressions or interpretations. Specificity is essential in the objective section so your supporting data is clearly identifiable. Without supporting data, your notes are simply opinions. Provide evidence to support your observations.
- Avoid vague language: Keep clear notes. SOAP notes are meant to be easy to follow, especially for other clinicians or providers who may need to read your notes. Overly descriptive language and irrelevant information can cloud your notes, which makes deciphering the notes more time-consuming. Being clear and straightforward when writing your SOAP notes will also help save yourself time when referencing past notes.
- Avoid repetition: While you may find yourself wanting to restate information from the subjective and objective sections, remember that this is not what the assessment section is for. Synthesize the information from the first two sections to make a note of any progress — or lack thereof — and determine what adjustments can be made. Analyze the subjective and objective information instead of summarizing it.
- Make adjustments instead of rewriting: When you determine where changes to the treatment plan need to be made, avoid rewriting the entire plan. This will waste your time since your client's goals should already be included in the plan. Record the adjustments you're making to the existing treatment plan and specify what immediate next steps you and your client will be taking to get closer to the goals the client set.
It's also worth noting that your SOAP notes don't necessarily need to follow that same order format every time. Some clinicians find success writing in an APSO order, but be sure to avoid the above mistakes even when writing in a different order.
SOAP Note Examples
The techniques for how to write medical SOAP notes are relatively simple and can be easily applied to behavioral health settings as well. Consider these examples of SOAP notes for counseling.
One of your clients, Mr. K, is a recovering alcoholic. During his appointment, he seems somber and admits he feels guilty about his drinking habits. Your SOAP notes for this session may look like a more detailed version of this:
- S: "I want my wife to know I feel guilty for the way I acted toward her when I drank."
- O: Tried to hide the tears in his eyes; Kept his gaze aimed at the floor; Wrung his hands together.
- A: Mr. K has become aware of how his drinking behavior has affected his relationship with his wife. He expressed deep emotions regarding his drinking and seemed to understand there are consequences for his actions.
- P: Write a potential apology letter to wife and bring it to the next session.
In this case, your client seems to be making progress in acknowledging how his actions have affected friends and family members. Your plan should reflect that and push him to take the next steps toward his goal of making amends.
A new client, Ms. G, arrives for her first appointment with you. Although this is her first time seeing a therapist and she doesn't have an official diagnosis yet, she is under the impression that she has anxiety based on her internet searches. For this client's notes, you'll want to gain as much preliminary information as possible to be able to eventually come to an official diagnosis.
- S: Gain an understanding of Ms. G's symptoms and what she experiences on a day-to-day basis. Accessing her family and medical history may also be helpful in this case.
- O: Make a note of the way she presents herself to you and how she acts during the session.
- A: Record your interpretations and create a list of possible diagnoses, ranking them from most likely to least likely.
- P: As a team, determine what Ms. G wants to gain from therapy and treatment and create objectives for moving forward.
Because this is only your first session with Ms. G, it's unlikely that you'll be able to determine a solid diagnosis without having follow-up sessions. Communicate that progress takes time, and you look forward to meeting with her again.
You diagnosed Mrs. D with depression last year, and she had made promising progress in the following months. At her most recent appointment, she didn't seem to be doing as well.
- S: Mrs. D reported only getting three to four hours of sleep at night, and before her appointment today, she hadn't showered for over two weeks.
- O: Mrs. D was quiet and only spoke when prompted; She was lethargic.
- A: Mrs. D appears to have regressed. She seems to be experiencing a depressive episode.
- P: Mrs. D has been referred to a medication evaluator.
After comparing the present SOAP note with notes from previous sessions, you were able to compare subjective and objective notes to determine that Mrs. D is showing signs of regressing to her previous depressive symptoms.
Additional Quick Tips for Writing Better SOAP Notes
Writing SOAP notes takes practice, and many healthcare professionals adopt the template after beginning their careers instead of learning how to write SOAP notes in school. As a behavioral health clinician with numerous duties and clients to see, documentation may be one of the last things you want to do. Despite this, quality notes can protect you from liability. Build your skills and consider these additional tips for writing better SOAP notes:
- Write notes for every session: For the most accurate SOAP notes, write your notes immediately after your appointments. If you wait until the end of the day after seeing multiple clients, sessions may blur together, and you may forget valuable information or get confused with another client.
- Use SMART goals in your treatment plan: SMART goals ensure your treatment plan is possible for the client. The plan you create should be Specific, Measurable, Attainable, Relevant and Timely.
- Properly correct mistakes: Ensure you know the accepted way of correcting mistakes made in SOAP notes. Using corrective tape or scribbling out your comments can make other clinicians question your validity. The proper procedure includes a singular, neat strike-through of the incorrect information. Then, date and initial that you were the one who made the corrections.
Pro Tip: Reduce Your Documentation Burden
Note writing and documentation are time-consuming. Spending an adequate amount of time on your notes can become a burden and take time away from other tasks like client appointments. Even with templates like SOAP, writing notes still takes considerable time and effort. As electronic health records (EHRs) become more common in healthcare environments, charting and note writing have been simplified. However, medical EHRs tend to lack features that behavioral health clinicians need to create adequate notes using the system.
Catch up to your medical colleagues and reduce the burden that documenting has put on you with ICANotes. Our EHR has charting features and templates to help make note writing and documentation fast with minimal typing. Designed by behavioral health professionals, the buttons in our software allow you to quickly document data like symptoms and observations. ICANotes also offers you the ability to customize your own buttons to fit your needs, and you may free-type in the notes as needed. Then, link notes together to track a client's progress.
Storing hand-written mental health notes or SOAP notes takes up a significant amount of space, and they can be easily lost in the event of a fire or theft. With ICANotes, you can easily scan and upload documents to keep all your files in one secure place. You can even send and receive documents using our secure faxing or direct messaging features. Using customized features and advanced security precautions, ICANotes complies with even the strictest of privacy standards.
ICANotes can help you get organized and take care of management duties, as well. Our EHR software allows you to manage a practice from any electronic device, eliminating the need for paper documents. You can scan insurance and determine insurance eligibility, submit and track claims, process payments and billing, organize scheduling and check-in clients with ICANotes for increased convenience and efficiency.
Our clinically robust features can help reduce your documentation burden, leaving you more time to create better, more effective SOAP notes.
Try ICANotes for Free
We understand that note writing is the part of the job that takes the longest. Luckily, writing SOAP notes can become an easy task. Use ICANotes to create high-quality notes in two to three minutes, giving you more time to spend with clients or manage other aspects of your clinical duties. Our team created ICANotes with behavioral and mental healthcare providers in mind. ICANotes' software is ready to go straight out of the box and is easy to use, so you can start reaping the benefits right away.
If you think ICANotes might be the solution you've been looking for, request a free trial and find out why it's the leading EHR software in the behavioral and mental health field. Contact our support team with any questions, for more information or to sign up for a live demo.
Clinical Director October has been a Registered Nurse for over 15 years. She is board certified in Mental Health and Psychiatric Nursing. She holds a Bachelor of Arts from the University of North Carolina at Greensboro. She also graduated with bachelor and master degrees in Nursing from Western Governors University.