Simple and effective SOAP notes

Maintaining good clinical documentation is a central aspect of providing patients with quality healthcare. To help you in your process of efficiently producing high-quality SOAP notes, we have collated a list of critical considerations to keep in mind when writing your clinical documentation.
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Quality Over Quantity: Conciseness is one of the essential features of a good SOAP note. While they should include all relevant information, your SOAP note should never exceed two pages in length. Avoid using vague language or repetitive sentences, and make sure that everything you include is relevant and informative. 
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Get Them Done: Physicians typically lead hectic lives filled with appointments, meetings, and administrative tasks. As such, it is easy to see how clinical documentation can be procrastinated. However, writing a SOAP note immediately after a session will ensure you haven’t forgotten any details that may be important: accuracy is critical! SOAP notes also shouldn’t take you more than ten minutes to write, so staying on top of them will be a more productive use of your time in the long run. 
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Maintain Professionalism: The subjective section of a SOAP note primarily refers to the opinions of the patient, not the physician. Although the physician needs to comment on their judgment of the patient’s symptoms, these judgments need to be backed up by factual evidence and not based on personal assumptions. Avoid words that have negative connotations, e.g., obnoxious or rude.
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Legibility: It might seem obvious, but the importance of having legible SOAP notes is often overlooked. If you choose to keep handwritten clinical notes, your handwriting should be neat and easy to understand. On the other hand, you might find it easier to guarantee legibility by writing your letters electronically. Specific healthcare platforms also offer SOAP note templates that can improve consistency and streamline your clinical documentation process.
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Storage: The information included in a SOAP note is often private. While SOAP notes can be shared between other healthcare providers and insurance companies, they must be stored securely.

While the specific information included in clinical notes will largely depend on your healthcare professional and the services you offer, the SOAP note structure can be effectively utilized by many different healthcare physicians. 
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‍Speech Therapy 
‍Excerpt from a subjection (S) section of a speech therapy SOAP note: 
‍Ben’s mother said that Ben is “initiating conversation more frequently at home and his teacher said he has been putting his hand up in class to answer questions more than he ever has before.” 
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‍Counseling
‍Excerpt from an objective (O) section of a counseling SOAP note: 
‍Sarah completed a Kessler-10 depression scale with a score of 25, indicating some presence of depressive symptoms. Sarah appears tired and disinterested, offering short responses to questions. Her sleep tracker suggests she has been sleeping an average of six hours every night.
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‍Mental Health
‍Excerpt from an assessment (A) section of a mental health SOAP note: 
‍Josh has made some improvements since the previous session. He reports sleeping an average of six hours uninterrupted sleep each night, which is a two-hour improvement from the last session. He is taking his medication regularly and reached his goal of completing thirty minutes of exercise three times a week. 
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‍Occupational Therapy
‍Excerpt from a plan (P) section of an occupational therapy SOAP note:
‍Angela should continue the current treatment plan, with one additional rep added to her knee exercises each week. The next session is scheduled for one week from today.
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‍Massage Therapy Excerpt from a subjective (S) section of a massage therapy SOAP note: 
‍The patient has a dull aching pain in his lower back that worsens with rotational movement. Symptoms have been present for six weeks. The patient has been seeking massage treatment weekly for the past four weeks. The current pain rating is 3/10.