Did you know that forms and other tools can actually make mental health counselor work easier?
In this power point presentation on SOAP Note Writing tips for mental health counselors you will take away 3 things:
- The #1 thing to remember when writing SOAP Notes
- A common mistake counselors make in writing notes
- How to help keep yourself out of legal trouble
Forms do not have be a necessary evil. They can and should be a dynamic guide that leads you and your clients successfully through the therapeutic process. These SOAP note tips will help you to really appreciate the need for a quality SOAP Note form.
The #1 thing to remember when sitting down to write your SOAP notes is who is your audience.
Ask yourself, “Who will be reading this note?” “Who is the audience?”
As you may know a SOAP Note becomes part of the client’s chart, aka the medical record. The therapist may keep therapy notes apart from the chart, but the SOAP note is part of the record which means it could potentially be viewed now or in the future by
- The client
- Other professionals working with client
- A judge or attorney
A very common mistake counselors make is not using a concise format when writing their notes and not being intimately familiar enough with the SOAP format to remain ethically, legally and professionally above board.
TAKE AWAY TIP: Frequently review tips on how to write a good SOAP note.
I don’t know about you but I always had trouble remembering what the acronym stands for and means. Let’s quickly review what SOAP stands for and I’ll give you a simple example to help you understand and remember the meaning of each letter:
Remember the S stands for subjective. Subjective data are typically things the client reported to you, “I am feeling very tired today and had trouble getting out of bed.” Subjective refers to data that are more like opinion. Statements colored by perceptions, feelings and experiences.
The O stands for Objective. Things you the therapist observed about the client. Objective data is measurable and observable. The client kept closing their eyes and their head was nodding. Medication was increased 1 week prior.
The A refers to Assessment. Your professional assessment based on what was reported and what you observed in the session, “Client appears to be over medicated.”
The P refers to the Plan. The plan is the action you and the client will take. In this case call a family member to drive client home. Contact the clients MD immediately to discuss symptoms and plan.
Can you see how using and being familiar with the SOAP format will help you stay focused on what is important?
Here’s another TAKE AWAY TIP: Before each session review your SOAP from the previous session. During the session review the key points from your note with your client.
By doing this the SOAP format drives the treatment forward.
You can also see how using your SOAP note in this provides the therapist and your client with accountability – by sticking to the SOAP format you will rest assured you are keeping the sessions client focused, remaining on top of important aspects of treatment and collaborating with your client to ensure they seeing the progress they hoped for.
Keep Yourself Out of Legal Trouble
Because many therapists do not ever get their charts subpoenaed, don’t work with adjunct professionals who need access to their records and rarely have a client who asks for a copy they get lax about asking the question to themselves each and every time they sit down to do a SOAP note “Who am I writing the note for?”…I am writing this for the medical record.
Ask yourself, if another professional read this SOAP note would they get a clear picture of the client’s symptoms, problems, assessment and plan of action? If the record is subpoenaed is it going to protect the client and the therapist because it is clear, consistent, accurate and measurable.
I am sure you can see at this point how having a good quality SOAP note with check boxes and prompts to remind you to address things like risk assessment, medication management, mental status, assessment and plan will all help to keep you professionally ethical and legally above board.
So remember to always ask yourself, “Who am I writing this SOAP note for?”
Consider who could potentially have access to or read the notes in the future
A good quality SOAP note guides you through the note writing process
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