CMD465: SOAP notes
Terms in this set (17)
Type of progress note, something that you write after a session
SOAP notes are used in pretty much every setting except
subjective, objective, assessment, plan
SOAP stands for
patients perception of an experience or how they feel, information supplied by the client or family member from their point of view (including complaints and symptoms), the clinician's opinion regarding relevant client behavior or status
Subjective part of SOAP notes
"Robert appeared tired and reluctant to cooperative during session today"
"wife comes in and tells you her husband is depressed" or client says "I did not sleep well last night, I am exhausted today"
test results or task data recorded from the session, something that can be seen or heard, how the client did on tasks throughout the session
objective part of SOAP notes
"With production of final /k/ in words, Robert achieved 85% accuracy (17/20)"
in SOAP notes, the assessment is NOT
conclusion based on combination of subjective/objective data interpretation with comparison to previous therapy performance
assessment part of SOAP notes
conclusion based on combination of subjective/objective data interpretation with comparison to to previous therapy performance
How did they do before vs compared to how they are doing now
"Today's results of 50% accuracy for plural 's' reflect a decrease in performance compared to the two previous sessions (70% and 75%). Clinician faded model on these tasks to a 5:1 ratio from a 2:1 for Robert and this may have been premature. Robert's fatigue may also have contributed to his performance"
testing or (more often) treatment plans
plan part of SOAP notes consist of
additional testing or treatment options, what you plan to do and therapy targets for the next session, date of next session
plan part of SOAP notes
"Continue to work on both /k/ production and plural 's' at the same levels but increase clinician modeling on plural tasks to a 3:1 ratio"
when to discharge, change therapy, or sitting in court
SOAP notes are helpful for
continual monitoring of treatment programs to better implement necessary changes immediately, informative to other team professionals working with client (PT, OT, social work, etc.), facilitate continuity of treatment in absence of primary clinician
3 important reasons for SOAP session notes