To effectively treat patients, doctors, counsellors and therapists struggle to understand the needs and concerns of each person they see. This understanding can grow more difficult if a patient sees multiple counsellors, because each counsellor may have his own opinion of the patient’s wants or needs. One solution to this problem is for the counsellors to use the SOAP format for taking notes. SOAP stands for subjective, objective, assessment and plan, and according to the Journal of Counseling and Development, this format allows for precise documentation and for holistic expression of needs and concerns of each patient.
Start the notes with the date and time of the patient’s interview or assessment, as well as the patient’s personal information, including name, contact information, sex, age and emergency contact person.
Complete the subjective section of the notes with information that the patient has related directly to you. This section includes opinion-based information from the patient: his feelings, concerns, goals for his therapy, etc. Include pertinent comments from friends, family, case workers or other people close to the patient.
Write only fact-based information in the objective section of the notes. This information includes quantitative, verifiable evidence, such as what can be directly observed by the five senses and by scientific measurements. This can include the patient’s appearance, any medical measurements taken and obvious behaviour.
Analyse the patient’s behaviour and problems in the assessment section of the notes. This section is often used to speculate a mental diagnosis or potential problems by combining the information from the first two sections and analysing it with professional thinking.
Create a plan for the patient’s treatment and record it in the final section of your SOAP notes. This section often includes the date and time of the patient’s next appointment, recommendations for interventions or notes of interventions attempted in the current session and a list of probable gains or goals based on the diagnosis and the client’s attitude toward therapy.
When completing the subjective section of the SOAP, keep direct quotes to a minimum. You should paraphrase in order to best convey the patient’s information in a brief assessment. Only include direct quotes if they pertain to potential harm for the patient or the people around him, or if they indicate a significant shift in mental state. Many counsellors use the phrase “as evidenced by” when documenting objective observations in order to back up their facts. The assessment section often includes “clinical impressions,” which are a counsellor’s unofficial diagnosis or notes on what diagnoses to rule out during the patient’s care. These must be carefully monitored, and always backed up with objective information, so that the counsellor does not appear unprofessional.