Salwa Zeinneddine • 2022-10-06
An Essential Tool for Documenting and Communicating Client Information
Sometimes, one might have nightmares for no reason at all. At other times, your work might be spilling over into your dreams! You are astonished. Aren’t you? Let me explain: you are a mental health provider struggling with hundreds of patient cases.
You scribble down unorganized therapy notes, and you end up crashing with therapeutic standards and regulations, not to mention the huge efforts you waste trying to remember clients’ information while deciphering useless notes. No worries, we understand how much you are going through; it is for this reason that this blog exists.
In this blog, we tackle one of the most important tools that will arm you with the ability to convey clients’ information accurately, clearly, and succinctly, thereby serving as a key skill you should strive to master: we are talking about SOAP notes in mental health.
Documenting clients’ information allows mental health providers to follow up with clinical encounters in a structured way. Generally speaking, clinicians use several means to organize their note-taking process with the intent of generating quick, clear, and effective therapy notes.
Typically, therapists choose the format they are most comfortable with as long as it ensures accurate documentation. This is mainly because there is no universally accepted progress note format.
Nevertheless, three of the most popular formats are SOAP, DAP, and BIRP notes. As SOAP notes, the cornerstone of this article consists of four sections: subjective, objective, assessment, and plan; each to be further expanded.
You Might Be Pondering "What to Include in a SOAP Note." Here’s the answer.
Subjective data of SOAP notes, as their name implies, includes subjective statements reflecting the client’s condition. This section assists you, as a provider, in keeping track of important information reported by the client(s). These include, but are not limited to, the client's presenting problems, statements elaborating on those problems, and any relevant history or notable event that the client brings up. Set the stage for this section by starting with direct documentation of the information as collected by the patient:
What brought the patient to you? His primary complaint, as stated by him.
A thorough report of the patient’s subjective history: the onset of his/her symptoms, reported physical and other concerns, palliating or provoking factors, the degree to which those symptoms are bothering your client (severity of the patient’s symptoms), history, etc.
Unsurprisingly, the objective section of your SOAP notes shall comprise objective, observable, quantifiable, and verifiable information as inferred from the client’s encounter. These encompass:
An introduction tackling the client’s overall condition
Objective observations, for example: "the client cried on two occasions, reiterating his desire to give up on everything."
Physical exam findings along with a general impression of the patient, followed by the results of any relevant diagnostic information you have performed. For example, "the client’s current score on the Beck Depression Inventory as compared to scores recorded previously"
Get your progress notes done in 2 minutes
After you have completed the subjective and objective sections of your SOAP note, it is time to delve into the craft of your assessment. In essence, the assessment section of your SOAP note can be viewed as a written evaluation of the client’s current session as it relates to the overall scope of therapy. This is your evaluation as a therapist of the effects of therapy to date. In short, the assessment section of your SOAP note helps you keep track of the:
Of course, it is not necessary to address each of those areas in every single SOAP note, but you are expected to include statements summarising information in the data sections along with comments assessing: the effectiveness of the session (e.g., the session seemed helpful in eliciting the client’s feelings about...), the overall effects of therapeutic interventions (e.g., the client continues to show steady progress in meeting treatment plan objectives), the client’s positive but also negative outcomes (e.g., the client reports increased suicidal thoughts), areas requiring more efforts (new stressors in clients’ lives, behavioral and environmental changes), a periodic assessment and revision of the effectiveness of treatment strategies (e.g., hypnotherapy has not proven to be effective to date), and finally changes needed to keep therapy on target along with diagnostic revisions.
Your SOAP note is not complete unless you explicitly explain the focus of future sessions based on the client’s current functioning level.
Delving into future therapeutic plans ensures adequate follow-up on the client’s progress and need for readjustments. In brief, the plan section of your note encompasses:
Homework assignments (assigned tasks to be completed outside of the counseling session, e.g., daily meditation, logging down feelings, etc.)
Upcoming interventions (new treatment modalities to be implemented)
Content of future sessions (problem areas that you will dwell upon during the upcoming sessions)
Treatment plan revisions (concerning whether objectives are being met or not)
Referrals (any referrals or additional suggested services, e.g., referral for medication evaluation)
You are not alone! We are here to transform the note-taking process into growth opportunities. With enough effort and time, you will become proficient in drafting vital psycho-therapeutical documentation. And keep in mind that, as with every skill you need to master in this life, practice makes perfect!
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