Accurately documenting a patient's mental illness is a requirement for a mental health professional. Knowing how to write psychotherapy SOAP notes helps you to effectively reiterate what has taken place during therapy sessions with clients. SOAP stands for subjective, objective, assessment and plan. Good psychotherapy notes corroborate the delivery of specified services, provide accountability as well as support clinical decisions. Learning to how to write SOAP notes is easy after a little practice and concentration. As a counsellor when you begin working with your client, ask yourself what are your client's mental health needs and how can they be met.
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Get information from the client's point of view. In the "Subjective" portion of psychotherapy SOAP notes you gather information from your client and the client's significant others. This data gathering section is about getting information about your clients feelings, plans, concerns, goals, thoughts, the severity of the problem and how it affects the people around your client.
Be objective in your observations. The "Objective" section of your SOAP notes involves documenting what you've observed when watching your client during sessions. Objective information is factual information about your client. When objectively writing about your client use terms in your notes that can be seen, smelled, heard, measured or count. Provide information about outside reports from other therapists, test results and medical records.
Begin to assess your client's situation. In the "Assessment" element of psychotherapy SOAP notes you show how the subjective and objective information about your client is interpreted, formulated and reflected upon. Write your notes as a psychiatric diagnosis. Include information of why you 'ruled in' or 'ruled out' a diagnosis. This section is read by other professionals and needs to contain sufficient data to help in their understanding of your findings in regards to your client.
Set a path of treatment. The "Plan" section allows you to document a way to treat your client. There are two parts to address in the "Plan" of your psychotherapy SOAP notes, "Action Plan" and "Prognosis". Include in the "Action Plan" the date of the next appointment, educational instructions, interventions used during sessions, progress of treatments and next session treatments. The "Prognosis" section includes a forecast of what the client will gain from your diagnosis and treatment as well as the client's motivation for preceding with treatment.
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