By the end of this brief power point presentation on SOAP Note examples you will take away these three things:
- Understand the SOAP acronym
- View a practical example
- See how a quality SOAP note does half the work for you
First, you should know that a quality SOAP Note form will serve to guide you through the documentation process. You’ll see exactly what I mean as we go through a SOAP Note example.
But first a reminder of what SOAP stands for:
S. Subjective: this is referring to what client tells you:
This would include symptoms, current stressors, and motivation level: what they are most interested in resolving or working on.
Use words like “client reported…” The S, O, A and P should flow from one element of the note format to the next to create a meaningful conclusion in the assessment and plan.
O. Objective data has to do with what the counselor observed about the client in the session. It should be documented in a measurable and observable way. The therapist may use words like “observed” in writing this section of the note…but keep in mind this is not your opinion – think measurable and observable.
A. Assessment – this is the core of your note – this is where you as a clinician take what your client shares (the subjective data) and assimilate it with what you as a professional therapist observed and try to make sense out of it for the purpose of helping your client.
P. Plan – is the action step both the counselor and the client are committing to. Plan can also include recommendations and referral information.
Here is a take away tip – Schedule time after each session to at least begin your SOAP. it should take about 5 minutes to write your SOAP. One of the problems we counselors run into when writing our sop notes is not making the time to complete them soon after the session. Commit to finishing your notes by the end of each working day.
In summary – SOAP stands for S= Subjective – this is your clients report, O stands for objective, this is largely the therapists measurable and observable observations, A stands for assessment, this is where you the therapist assimilate the S and O and finally the P or Plan which is the action steps you and your client will take.
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