3 SOAP Note Examples to Help You Write Progress Notes

As a health professional, writing progress notes is a time-consuming part of the job. Using tailored models is key to an efficient writing process and standardized notes.

In this article, we'll delve deeper into an effective way for consistently documenting your client's information: SOAP notes.

We’ll explore each component, provide tips and SOAP note examples for effective documentation.

Whether you're new to using SOAP notes or looking to refresh your knowledge, this guide will help you write clear, concise, and comprehensive SOAP notes.

What is a SOAP note?

SOAP notes are a widely used method of documentation in the healthcare field, particularly in settings where a client's progress needs to be tracked over time.

The SOAP note format was developed by Dr. Lawrence Weed in the 1960's as a way to organize client information in a structured and concise manner. It was initially used in medical records but has since been adopted across various healthcare disciplines, including mental health, occupational therapy, social work, speech therapy, and more.

One of the key strengths of SOAP notes is their effectiveness in documenting progress and conveying relevant information about the client. Whether you're a mental health counsellor documenting a therapy session, an occupational therapist assessing a client's progress, or a speech therapist tracking a client's language development, the SOAP format provides a systematic approach to documentation.

SOAP stands for:

• S
  Subjective
• O
  Objective
• A
  Assessment
• P
  Plan

SOAP Note Variations

In addition to the traditional SOAP format, there are variations that offer slightly different structures and focuses that may be taken into consideration when choosing a template.

APSO Notes: The APSO format places the Assessment and Plan first, followed by the Subjective and Objective information. APSO notes are often used in settings where the assessment and plan are the primary focus, and require even easier access.

SOAPE Notes: The SOAPE format adds an Education or Evaluation section after the Assessment. This format is particularly useful when documenting an evaluation of the plan or advice transmitted to the client about various aspects of the treatment process is important.

Ultimately, the choice of format should align with the goals of the documentation and the specific needs of the setting. Whether using the traditional SOAP format or one of its variations, the key is to ensure that the note is organized, concise, and effectively communicates the necessary information for continuity of care or evaluation.

Best practices for writing effective SOAP notes

Progress notes are not only a legal requirement for certified mental health professionals, but must also comply with specific standards for both public and private contexts. When writing a progress note, it's essential to consider the following criteria to determine which information to include:

• Relevance: Ensure that the information is pertinent to the client's treatment and progress.
• Organization: Arrange the information in a clear and logical manner.
• Conciseness: Be brief and to the point, avoid unnecessary details.
• Objectivity: Present factual information without personal bias or interpretation.
• Accuracy: Ensure that the information is correct and reflects the client's actual progress.
• Clarity: Use straightforward and easy-to-understand language.
• Legibility: Write in a neat and readable manner.
• Spelling: Check for and correct any spelling errors.

When writing a SOAP note, it’s important to follow the general guidelines for progress notes. The information under each heading should be relevant to the client in question and to the specific consultation context.

Here are some tips for each section:

Download our free PDF template to start using the SOAP notes template in your clinical note-taking.

SOAP Note Examples

Below are examples of SOAP notes in various clinical contexts. Please note that these are for illustrative purposes only and should not be used for actual clinical documentation.

SOAP Note Example for Mental Health Counselling

In mental health counseling, SOAP notes can help document client sessions and track progress, especially with regard to a client's mental health status and treatment plan.

Subjective

Client reports feeling overwhelmed with work and personal stressors. He describes feeling anxious most of the time and having difficulty sleeping. Client reports increased irritability and difficulty concentrating.

Objective

Client's affect is anxious. He appears tense and fidgety during the session. Client's speech is rapid, and he often interrupts himself. Client's body language suggests discomfort.

Assessment

Client presents with symptoms consistent with generalized anxiety disorder (GAD). Client's symptoms are significantly impacting his daily functioning and well-being. Differential diagnosis includes adjustment disorder with anxiety.

Plan

• Continue weekly counselling sessions to address anxiety symptoms and coping strategies.
• Discuss stress management techniques, including mindfulness and relaxation exercises.
• Refer client to doctor for evaluation and possible medication management.
• Schedule follow-up appointment in one week to monitor progress and adjust treatment plan as needed.

SOAP Note Example for Occupational Therapy

SOAP notes offer a structured approach to documenting client assessments, interventions, and outcomes for occupational therapists. They help facilitate effective communication among healthcare professionals and ensure comprehensive client care.

Subjective

Client reports increased difficulty in performing activities of daily living (ADLs) due to pain and stiffness in the right shoulder. Client states that the pain has been present for the past month and has worsened over time. Pain is rated as 6/10 on the visual analog scale (VAS).

Objective

• Observation: Client demonstrates guarding of the right shoulder and limited range of motion during shoulder abduction and flexion.
• Range of motion: Right shoulder abduction limited to 90 degrees, flexion limited to 100 degrees.
• Strength: Weakness noted in the right shoulder, particularly in abduction and flexion.
• Palpation: Tenderness and palpable stiffness noted in the right shoulder joint.

Assessment

Client presents with symptoms consistent with adhesive capsulitis (frozen shoulder) of the right shoulder. Pain and stiffness are significantly impacting the client's ability to perform ADLs independently.

Plan

• Begin treatment with modalities to reduce pain and inflammation, such as ice and ultrasound therapy.
• Initiate a home exercise program focused on improving range of motion and strength in the right shoulder.
• Educate client on activity modification and ergonomic principles to prevent exacerbation of symptoms.
• Schedule weekly occupational therapy sessions to monitor progress and adjust treatment plan as needed.

SOAP Note Example for Social Work

Here is an example demonstrating how social workers can use SOAP notes to document client interactions, interventions, and assess needs. In this context, SOAP notes help track progress, facilitate collaboration with other professionals, and ensure effective care.

Subjective

Client reports feeling overwhelmed with financial stressors. She recently lost her job and is struggling to make ends meet. Client expresses feelings of shame and embarrassment about her current situation.

Objective

• Observation: Client appears anxious and restless during the session. She avoids eye contact and fidgets with her hands.
• Housing: Client is currently living in a shelter and is concerned about finding stable housing.
• Support system: Client reports limited support from family and friends.

Assessment

Client presents with acute stress related to recent job loss and financial instability. Client's feelings of shame and embarrassment are impacting her self-esteem and ability to seek help.

Plan

• Provide crisis intervention to address immediate needs, including connecting client with resources for food, housing, and financial assistance.
• Develop a safety plan with client to address feelings of hopelessness and suicidal ideation.
• Refer client to a support group for individuals experiencing similar challenges.
• Schedule follow-up appointment in one week to monitor progress and adjust treatment plan as needed.

How to write SOAP notes with Psylio

Psylio is a comprehensive recordkeeping platform designed to streamline note-taking, client appointments, and financial management. With built-in templates, such as the SOAP notes template, using Psylio can help you save time and simplify your workflow.

To access the SOAP note template directly integrated into your client progress notes:

A SOAP note is one of several models used in clinical note-taking. And while writing progress notes can be tedious, it's a crucial part of the clinical process.

Using templates based on your preferred models makes progress notes easier to create and ensures standardization across all your notes and among the various professionals in an organization.

Whether you use the templates directly within the Psylio platform or save our free PDF for later use, having access to these tools can free up more time for what matters most - your clients!

About the author

Sophie Tremblay

Content Specialist, B.A.

Sophie excels as a French and English content specialist and project coordinator for Optania. With a Bachelor of Arts and a double major in French and English literature, her linguistic expertise brings rigour and excellence to the content produced by the team.

Her experience in coordinating content writing, conducting specialized demonstrations and training, and supporting customer service operations demonstrates her continued commitment. Her passion for language and creating quality content is a constant source of motivation in her work.

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