Does it ever get tedious writing SOAP notes after each patient session? Although the framework’s been around for over half a century, it’s not always a breeze getting concise, relevant information written down in a timely manner between clients.
You might recall that SOAP notes were introduced by Dr. Lawrence Weed in the 1960s because he was fed up with the lack of a standardized documentation process. That first iteration was called Problem Oriented Medical Record or POMR. SOAP notes evolved from POMR, and are now considered the ABA industry’s gold standard note-taking format.
If you’re reading this, it’s possible you’ve been writing SOAP notes since you’ve begun your practice. But you may not have been trained on how to write them efficiently so that they create maximum value to your client’s interdisciplinary team.
Here’s the agenda:
- Review the components of SOAP notes
- Why SOAP notes are important
- Common mistakes in writing SOAP notes
- Tips to write better SOAP notes
- How SOAP notes may be different for psychotherapists
- Best practices
DEFINING THE COMPONENTS OF SOAP NOTES
The acronym SOAP stands for Subjective, Objective, Assessment and Plan. A SOAP note conveys session information that can be used in conjunction with other treatment providers in regard to a patient’s plan of care. Healthcare is increasingly a team approach so communication must be clear and collaborative while HIPAA laws in mind.
SOAP notes maximize the value of your case notes by organizing perceptions, observations, metrics, and analysis in order to meet the treatment needs of clients. These progress notes are included in the client’s treatment record and can be shared with the interdisciplinary team.
- SUBJECTIVE is qualifiable or descriptive information expressed by the client, or the client’s family, that is based on revelation, feeling, or observation. This can include patient quotes, attention, and engagement level.
- OBJECTIVE is quantifiable or measurable information. This would include the specific objectives that are used to meet goals for such things as IEPs or 504 plans.
- ASSESSMENT is the section where you, as the provider, assess and document your synthesis of the subjective and objective sections of the SOAP note. This can include the effectiveness of treatment or its inefficacy.
- PLAN is for writing down what will come next in your client’s plan of treatment. You will include any short or long term goals, frequency, and length of therapy and any plan of treatment changes.
SOAP notes are meant not only to organize your client session, but to create actionable treatment plans that can be shared with other members of the interdisciplinary team. Keep your SOAP notes fresh and clean.
WHY SOAP NOTES ARE IMPORTANT
The SOAP notes you take to document each ABA therapy session can also be used to substantiate billing claims sent to insurance providers. They also communicate to your client’s interdisciplinary team your rationale for ongoing services.
SOAP notes are also important because observations aren’t always subjective. Some observations can be measurable. For instance, a diagnosed narcoleptic client falls asleep for 10 minutes in the therapy session. You wouldn’t just assume that the client was tired when you should have it in your team notes that your client is narcoleptic which would lead you to time the amount of sleep during your session. This is why taking good SOAP notes is imperative across-the-board.
COMMON MISTAKES IN WRITING SOAP NOTES
Writing good SOAP notes keeps your practice healthy and reputable. A common mistake is to not document after every session. Brains are a tricky beast when you wait until the end of the day to write all your SOAP notes, especially if you see multiple clients each day. Documentation isn’t an afterthought. If you simmer information about your client throughout the day, your notes may not be accurate or complete. This can not only increase mistakes and liability, but delay insurance reimbursement.
Other common mistakes include mixing the qualifiable subjective and quantifiable objective sections, making an assessment without synthesizing the information from those sections, and making a plan of treatment without knowing the difference between goals and objectives.
Objectives are specific plans that will help your client with a general goal. Make sure that your planning section includes modality, frequency, and targets to reach those goals.
Remember: what you write is opinion until you back it up with supporting facts. If it’s subjective, provide the evidence for what you observe. For instance, if you note that your client seems worried or voices that worry, back it up with what your client is doing to evidence that worry–like pacing back and forth or wringing their hands. Be concise, don’t use slang or unprofessional phrasing. Electronic SOAP notes are preferred over hand-written notes as electronic records can be shared more easily among members of your client’s interdisciplinary team.
If you make a mistake in your SOAP notes, don’t erase it. Don’t cover it up with correction tape. Strike-through the error once, cleanly and neatly. Initial and date next to the error. Correct any errors next to the error. Only you should correct your own errors–always.
TIPS TO WRITE BETTER SOAP NOTES
Writing good SOAP notes is a deliberate practice, but not one that should be undertaken during your client session. It distracts both you and your client from the session at hand. Personal notes are fine to help you write your SOAP notes after your session has ended. It is helpful to use acronyms when possible when writing your SOAP notes.
Use the OLD CARTS acronym for the subjective section:
- Onset
- Location
- Duration
- Character
- Alleviating or Aggravating Factors
- Radiation
- Temporal Pattern
- Severity
As an ABA provider, you may not use each subsection. But your client’s PCP and other providers might, so you need to recognize the acronym and what each subsection means.
Back up everything you write in your objective section with its supporting data. This includes areas of concern and their short-term and long-term goals.
Synthesize the information and data in your subjective and objective sections so that you can make an unbiased evaluation that is data-driven in your assessment section. Track your client’s progress through a systematic review of previous visits. Your assessment synthesis should lead to your care plan, but you can’t assess using just one point of data, you need a range in order to assess your client’s progress or setbacks.
The plan section should present SMART goals. As an ABA provider, you should always be mindful of keeping your treatment plan Specific, Measurable, Attainable, Relevant and Timely. This not only maintains consistency but shows your interdisciplinary team how you plan to meet goals and objectives.
HOW SOAP NOTES DIFFER FOR PSYCHOTHERAPISTS
Psychotherapists notes differ from SOAP notes in that SOAP notes are standardized and included in your client’s record while psychotherapy notes, while covered by HIPAA, are not included in your client’s record. There’s no one way to write a psychotherapy note as they are not standardized. And remember–clients DO NOT have a right to read your psychotherapy notes.
BEST PRACTICES
You want to be ready for an internal or an external audit at all times. By detailing your SOAP notes at the end of every ABA client session, you are not only writing the notes while the information is fresh in your mind, but covering yourself and any company you work for from liability. Always write your SOAP notes like you will have to defend them in a dissertation. If you’re audited, you may have to defend them.
Besides your SOAP notes, you should find the following in your patient’s ABA file: assessments taken and their corresponding protocols, consent forms for treatment plans, synthesized progress notes with accompanying graphs and charts, as well as any discharge plans and forms. Document well all home visits, interventions and strategies that aid in your client’s skill sets. It’s usually a requirement for billing.
Follow all federal, state and local laws for privacy. They continually evolve, so check with your parent company if you need clarification. If you’re in private practice, check with your lawyer.
What you do as an ABA provider is not only dependent on your own skill set, but on how you approach your documentation practices and where you want your practice to go in the future. Your SOAP notes should reflect not only your client’s subjective and objective needs, but in a sense, they will reflect a certain quality of life through their communication, language and social skills.
As an ABA provider, continuous education will help you write your progress notes and show your client’s interdisciplinary team that your professionalism is one that they can count on for accurate plan of treatments.
This post is for informational purposes only and is not meant to be used in lieu of practitioners own due diligence, state and federal regulations, and funders’ policies. During the Coronavirus pandemic, and when implementing telehealth, be sure to use your resources and complete the proper follow-up with funders and insurance.
