If you are a healthcare practitioner, you certainly know the importance of organized and detailed medical records documentation. Typically, healthcare professionals deal with multiple issues simultaneously, so having a way to organize the client’s data in a simplified and organized manner comes in handy.

This is where SOAP notes which were created by Physician Lawrence Weed in the 1950s, come in. They were originally called a Problem-Oriented Medical Record (POMR). SOAP notes capture a client’s specific information and some aspects of their session.

Let’s take a look at how to write a SOAP note.

How to Write A SOAP Note Correctly

You must follow a precise structure, hitting every SOAP acronym’s letter. You can organize your notes well through the SOAP note and diagnose, assess, and treat your clients using the right information.

With that said, let’s go through each letter of the acronym.

S- Subjective

This section covers the subjective experiences or personal feelings or views of someone close to the patient or the patient themselves. Ultimately, it offers context for the plan and assessment.

You will enter the information concerning the client’s presenting problem, chief complaint, and even direct quotes from them. You can also include medications, mental and medical history, and daily routines.

Moreover, You should include unsourced opinions and statements without factual information supporting them.

O- Objective

Here, you will document measurable, factual, and quantitative data. This includes a session’s specific interventions.

Moreover, quantifiable outcomes such as test scores, diagnosis, orientation, physical symptoms, affect/mood, appearance, and body posture.

This section’s content includes the client’s strength, mental status, ability to take part in the session, and their responses. In addition, you can have the general appearance, psychological, interpersonal, and physical observations, and written materials like psychological tests.

Avoid personal judgments, labels, general statements, and value-laden language. Moreover, don’t use phrases/words with negative connotations and assumptive statements about behavior.

A- Assessment

You will describe your session’s interpretation and how your client is progressing towards attaining their goal. Develop your official statement by combining the S (Subjective) and O (Objective) sections.

This part should have:

• Therapeutic Model/ DSM criteria to identify the problems and treatment.
• Professional and clinical knowledge to explain the issues of your client.
• Your objective and subjective information analysis.

Don’t repeat statements from sections O and S.

P- Plan

The final part entails outlining the trajectory of the treatment plan based on the issues you identified. Therefore, state all the objectives, reinforcements, or activities you intend to change, which can include:

• Any nutritional, mental, or physical elements that might have an effect.
• The regression or progression your client had.
• How you will implement the following steps and treatment.
• The steps for the upcoming sessions.

Don’t rewrite your whole treatment plan or include unrealistic/immeasurable goals. Instead, use this section to track your client’s progress and make necessary adjustments to the plan to help the client attain their goals.

Also, read: How To Write A Capstone Project Like An Expert

Conclusion

A SOAP note is essential to anyone in the healthcare industry. They include medical doctors, nurses, dentists, veterinary practitioners, psychologists, and emergency medical technicians.

Knowing how to write a SOAP note ensures you come up with a plan any provider can decipher immediately.