SOAP Notes: How a 50-Year-Old Medical Format Stays Current

If you’ve ever wondered about the way a medical health professional documents his patient, then you need to know more about SOAP notes.

A primary medical and telehealth tool, these important documents help doctors everywhere, helping them keep track of patients, organize information, and deliver better quality healthcare.

In this article, we’ll define SOAP notes and consider their specifics, then consider how they apply to psychological practice.

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What Is a SOAP Note?

SOAP notes were developed in the 1950s as a means of keeping track of patients with multiple conditions. Patients who had to be seen by many specialists had to have a comprehensive medical file with notes from every check-up to be assessed correctly and efficiently by any doctor.[1]

How SOAP Notes Benefit Practitioners

SOAP progress notes are a clear and effective way of organizing medical data in a neat way, making a doctors’ work easier when it comes to catching up with a patient.

Another great advantage of using SOAP notes is that, by keeping the same structure in organizing medical information, they help doctors exchange information between disciplines, without losing focus on the most pressing problems.

SOAP notes, for instance:

• Can be used by your GP when doing your annual routine check-up.
• They can also be used by paramedics on an ambulance when assessing you, and
• Later, they help hospital staff when you are admitted.

Each helping professional in this chain can use your notes to quickly understand your condition, what needs to be solved first, and the measures that have been taken so far.

SOAP progress notes are a clear and effective way of organizing medical data in a neat way, making a doctors’ work easier when it comes to catching up with a patient.

The Components of a SOAP Note

If you want to understand what SOAP progress notes are exactly, then we need to break them into the four categories that make up their name:

• Subjective
• Objective
• Assessment, and
• Plan.

The Subjective Component

The subjective component represents information gathered directly from the patient (or their representative, if they cannot speak for themselves.)

This is called a subjective component because it refers to the way a patient sees their condition and what they perceive as their goals and needs.

Having this component written down clearly, or storing it in a secure digital e-health system helps doctors better communicate with patients. It helps them cooperate over the next steps of the medical examination building higher patient health engagement over the long term.

It includes data on:

• Chief complaint (CC): Finding out from the patient why they are requesting medical services. The doctor will often include a quote from the patient in the SOAP note, telling exactly what they are experiencing.
• History of Present Illness (HPI): The doctor will ask questions about the history and current state of the CC (chief complaint) to better find out what approach is best. Various information is collected, from medical and surgical history to social history and family history.
• Review of Systems (ROS): Other symptoms that may be bothering the patient.

A Closer Look

One of the ways in which medical professionals make sure they gather as much information as they can is to use a template of questions or things to take into consideration.

There are a few very simple models that can be easily used to cover most of the relevant aspects.

One popular mnemonic is the OLD CARTS acronym, which stands for the following[2]:

These practical tools help medical professionals keep their notes organized and easy to navigate through, while still touching all the major points in a patient’s treatment plan.

The Objective Component

To check the validity and extent of the chief complaint, a doctor needs further information. This time, of objective nature.

This may include results from past medical tests for the same complaint, along with on-the-spot observations made by examining the patient.

This is the kind of information that is written down in the Objective part of a SOAP note and includes[3]:

• Measurements and where the patient fits on an average scale;
• Vital signs: heart rate, heart pressure, pulse
• Observations of the affected system;
• Exploring possible involvement of other body systems in the condition;
• Evaluation of pain – different scales can be applied;
• The psychological state of the patient;

The difference between the objective data collected in the first phase and the subjective data from that the latter is that the former is measurable, and only based on facts. If symptoms are narrated by the patient themselves, signs in the objective component of the SOAP notes are based on the doctor’s observations.

Potential differences between the subjective and the objective parts are important in assessing the patient correctly and not treat the diagnosis superficially.

Needless to say, correct treatment depends on a real diagnosis, and some mental health patients might incorrectly assess their condition or exaggerate the facts, knowingly or unknowingly.

The Assessment Component

From the information gathered so far, a doctor can then assess the nature and severity of a patient’s condition.

The assessment component starts with a quick summary of the condition that brought the patient into the cabinet or the hospital and continues with a perspective of how the condition evolved in time, or from the last visit.[4]

Over the length of the treatment plan, each SOAP note should contain a progress evaluation observation in the assessment field.

The Plan Component

The plan component of a SOAP note refers to future investigations and treatment schemes that the doctor recommends, based on the information gathered so far.[4]

It also includes the main points of discussion that were approached with the patient, as well as when the next follow-up is to be expected.

This helps the patient have clear instructions on what to do next, as well as other health care specialists who will see the patient further.

In a Nutshell

This four-component method of gathering medical data is very practical and comprehensive, and the fact that most doctors use it gives the entire medical experience a more unitary and holistic approach.[5]

Often, patients come to the doctor’s office with more than one condition. For such patients, the plan component should address each diagnosis separately and clearly separate them by numbering or marking them one way or another.

• For diagnoses not covered by one doctor’s specialty, a recommendation for a different practitioner can be written – another way SOAP notes facilitate collaboration in healthcare systems.
• Alternatively, patients may easily be sent for medical testing elsewhere, in a reasonable timeframe for quality care.

If you’re looking for discipline-specific guides, check out our article on How To Write Occupational Therapy SOAP Notes (+ 3 Examples).

SOAP Notes in Mental Health Care

Taking notes is crucial in behavioral therapy, as there are fewer methods of gathering empirical data than in other sectors of medicine. Psychology, psychiatry, their blended care models, and their sub-domains rely heavily on observation and interviewing for diagnosis and creating a treatment plan.

SOAP notes provide crucial information on the progress of the patient and what to consider next time they attend therapy.

The SOAP notes format, like BIRP Notes, can be used for any behavioral health service, from psychiatry to speech therapy or psychology. If you are not yet familiar with how SOAP notes are applied in mental health, here are some detailed applications.

SOAP notes provide crucial information on the progress of the patient and what to consider next time they attend therapy.

SOAP Notes in Psychiatry

Psychiatry, compared to psychology, treats mental health illnesses and not a minor disturbance in personality or just mood changes alone. This is why medication use is more prevalent in psychiatry and the drugs used are more potent.

A psychiatrist has an important job of evaluating his patients every time they show up for their appointments, performing checks regarding their mental state, cognitive abilities, moods, symptoms, and treatment plan.

SOAP notes integrate perfectly in a psychiatrist’s workflow, both in digital and conventional formats for telepsychiatry, giving practitioners insight into:

• Past medical events – including diagnoses, medications, and treatments
• The patient’s present situation, and
• Whether the last mental health plan needs to be improved or not.

SOAP Notes in Therapy

In individual therapy, treatment plans are largely based on the subjective component and thus contain fewer data to process in the objective phase.

Talking to the patient in the office or online, observing their behavior, and gathering contextual clues from them and/or their caregivers is crucial in confirming diagnoses.

Writing and storing SOAP notes is also important for situations such as malpractice suits or change of therapist. Having clear documentation of the patient’s progress is also critical for their health and how their insurer will decide to cover for their treatment.

SOAP Notes and Group Therapy

When it comes to patients in group therapy, it might seem impossible to keep track of such detailed observations for each.

But group therapists do exactly that, and SOAP notes are fantastic tools for gathering information. Each participant in group therapy will have a separate SOAP note, with all the four components covered.

When integrated within larger e-mental health plans, referencing, note-taking, and document referral becomes faster and much more convenient.

This is why it’s encouraged that everybody gets to talk in group therapy, although not a rule. The therapist will include non-participation as a symptom in his SOAP notes, and change the plan for the next session.

SOAP Notes in EHR Systems

One of the most interesting things that SOAP notes brought in the medical world since their implementation in the 1960s is the fact that it easily connects medical data from one doctor to another, helping them provide more accurate and faster treatment.

With the creation of EHR systems (Electronic Health Record) technology allows doctors to instantly check a patient’s medical history. Still, the data is entered by humans, and the SOAP note system has proved to be timeless in terms of simplicity and efficiency.

EHR and EMR systems are widely based on SOAP notes, providing a homogenous way of gathering medical data, regardless of the specialty, location, or language.

Having a “common language” for taking notes helps doctors become more interconnected, so they can collaborate more closely to treat and educate patients.

Having a “common language” for taking notes really helps doctors everywhere become more interconnected to each other, so they can collaborate more closely to treat and educate patients.

Benefits of SOAP Notes in EHR

If the use of handwritten SOAP notes has helped doctors connect to each other, EHR based on the SOAP template is really making the data transfer instant. Clear and concise notes are needed in medical practice, as doctors have limited time with patients, and must draw some kind of conclusion end of a meeting.

While SOAP notes are, indeed, a great tool for behavioral therapists, they do have certain disadvantages. One of these is not having a clear sub-category were differences between notes can be highlighted and easily checked.

With EHR, however, there is the possibility of quickly identifying such differences, which helps a lot in the treatment of chronic patients or patients with addictions, for example.

Where Can SOAP Notes Be Used?

There is such a high efficiency in how SOAP notes work, that they have been used outside the medical world, too.

If at first, it was the physicians who were taking such concise and organized notes, now it’s common practice for any medic. More so, it is presently used in counseling, coaching, speech therapy, and other professions that complement conventional therapy and psychiatry.

Final Thoughts

SOAP notes are still around because they work. EHR has changed many things in how medicine is practiced, but it still takes its model after the SOAP notes that were created decades ago. Their simplicity, together with a comprehensive view of a patient’s progress are the two characteristics that make them so efficient.

Patients can also become familiar with how SOAP notes work just by reading their medical records. That’s how they can learn how to organize them before going to the next appointment. Keeping medical records in the SOAP format helps patients defend their case when suing for malpractice or workers’ compensation, for example.

SOAP notes have not changed much, but EHR gives them a new dimension. We are excited to see how many more applications they will have in the future.

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