A few weeks ago I made twitter friends with Abhay from PsyPack. PsyPack is a start up working to make it easy for clinicians to regularly provide clients with standardized assessments. That peaked my interest. As long time readers of this blog know regular assessments are part The Big Three. So I began poking around their website and came across this blog on how to write notes.
How to write a good note is something I've repeatedly heard as a pain point from clinicians, so I reached out and PsyPack gave me permission to repost it.
So if you're one of those clinicians who's not sure how to write a good note, or if you interested in regular assessing check out PsyPack. Tell them Abhay sent you.
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Documentation is an age-old idea which has existed since the existence of language. One of the use-cases of documentation has been to preserve history. In medical science, one thing common to all treatments is patient history. Patient history ranges from symptoms, diagnosis, intervention, medication and vital parameters etc. With such diverse information, it becomes helpful to have a framework of organising this information. One of the very first attempts to have such a framework was made by Dr. Lawrence Weed in the 1960’s at the University of Vermont1. This framework was called the Problem-orientated medical record (POMR). Over time, various disciplines adapted this framework to their own specific uses and evolved into modern note-taking frameworks like SOAP notes, DAP notes and BIRP notes.
SOAP documentation format commands a widespread adoption in the field of healthcare across specialities. This clear, concise and well-organised documentation format has become one of the favourite notes frameworks of behavioral health practitioners. Let us deep dive and learn more about this format.
What is a SOAP note?
The Subjective, Objective, Assessment and Plan (SOAP) note is an acronym represents a cognitive framework to help healthcare professionals organise treatment information of a client in a highly structured format.
SOAP Notes template with example
A SOAP note is structured into four parts.
This section focusses on the subjective experience of the patient or their caretaker. It includes the symptoms they are experiencing, feelings with regards to the illness, medical history, previous diagnosis (if any), and their personal views. Simply put, this is what the patient says about their problem [emphasis mine - JH].
Example: 37-year old female presenting chest pain, decreased appetite and shortness of breath. Diagnosed with mild depression 1 year ago. Underwent psychotherapy for 3 months. Recent physical manifestations concurrent with family feuds.
The focus of this section is on objective data. This includes vital signs and symptoms, findings of the clinician, laboratory diagnostic data and objective reports from other clinicians. Unlike the “Subjective” section which gives a description of patient’s own account, the “Objective” section is backed by evidence [JH]. An example of this is a patient stating they have “stomach pain,” which is documented under the subjective heading. Versus “abdominal tenderness to palpation,” an objective sign documented under the objective heading.
Example: The client's results on the Depression, Anxiety and Stress Scale (DASS) signals moderate depression, extremely severe anxiety and mild stress.
It is recommended that you store the data in the client’s file securely in accordance with HIPAA2 . PsyPack is a HIPAA compliant software you can use to conduct psychometric assessments with your clients. It can help you maintain client notes automatically and save you tons of time.
This section is the clinician’s analysis of the subjective and objective evidence to arrive at a diagnosis.
For behavioral health practitioners, one would generally expect a differential diagnosis where they would list various problems in order of importance. At this stage, therapists could mention ICD-10 or DSM-5classification of the illness 3,4. This can be particularly helpful for therapists who are empanelled and accept insurance plans like United Healthcare, Aetna, BlueCross and BlueShield etc 5,6,7.
Example: Client is most like suffering from Generalized Anxiety Disorder (ICD-10 code F41.1)8.
This section details the treatment approach – interventions, goals/objectives of the intervention, expected time frame, and follow-up and next steps.
In case, further information is required for planning the treatment, this section will include plan (additional testing, consultation with other clinician etc.) to obtain the required information.
Example: Immediate initiation of pharmacotherapy and, if severe impairment or poor response to therapy, expedited referral to a mental health specialist for psychotherapy and/or collaborative management.
DAP Notes and BIRP Notes
SOAP notes are not the only format available for charting treatment. The other popular approaches include DAP (Data, Assessment, and Plan) and BIRP (Behavior, Intervention, Response, Plan). Among all these formats, SOAP notes format is most widely used.
You should choose the format of documentation based on what’s best suited to your practice. But having a framework can be really helpful. Additionally, you must be wary to not adjust your treatment to fit any particular format. Always remember, treatment notes follow the treatment and not vice versa.
PsyPack Practitioner’s Notes
At PsyPack, we are constantly working to ensure that therapists are empowered with technology to streamline their practice. Apart from helping you embrace evidence based approach by digitising a wide range of psychological tests, we now allow you to add your own therapy notes to the assessment reports. You can now add notes in any format in the “Practitioner’s notes” section of reports. Try it out.
Today the world is increasingly moving towards mandatorily maintaining treatment documentation. A part of this shift is to ensure best practices, choice of patient to switch their clinician, insurance empanelment and claim settlement etc. To stay competitive, it is critical to embrace best practices and technology in your therapy practice.
That's how you do SOAP notes. I took the liberty of writing out the full note.
37-year old female presenting chest pain, decreased appetite and shortness of breath. Diagnosed with mild depression 1 year ago. Underwent psychotherapy for 3 months. Recent physical manifestations concurrent with family feuds. The client's results on the Depression, Anxiety and Stress Scale (DASS) signals moderate depression, extremely severe anxiety and mild stress. Client is most like suffering from Generalized Anxiety Disorder (ICD-10 code F41.1). Immediate initiation of pharmacotherapy and, if severe impairment or poor response to therapy, expedited referral to a mental health specialist for psychotherapy and/or collaborative management.
Notice how short it is. Following this format you're no longer wondering "am I including the right thing." And you're no longer doing hours of notes. These notes a professional, short and simple.