SOAP Notes – Example, Template and Format
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.