The SOAP note format has been in wide use in the medical community for decades. Dr. Lawrence Reed developed the problem-oriented medical record decades ago and from that, SOAP emerged. For mental health professionals, SOAP is tried and true. Although the behavioral health profession uses a variety of different clinical note formats, SOAP is still a fundamental format worth knowing about!
Components of a SOAP Note
This is also known as the “chief complaint.” In other words, this is a brief statement of why the client is seeing you. “What brings you to see me today?” This section might include the client’s history, as told in their own words.
This is the part where you include your observations of the client. These might be findings from a physical exam, vital signs, weight, lab tests. It also might include observations you’ve made: “Foul odor,” “Rapid speech,” “Quick eye movements.” With behavioral health, “objective” can be difficult since much of the mental health practitioners work is interpretive and not as purely objective as a blood test rest. But for the purposes of a mental health SOAP note, objective could be considered analogous to “Observations.”
This is the diagnosis, including a differential diagnosis when appropriate, especially since many behavioral health conditions don’t always present in an unambiguous way: there are co-morbidities, similar symptoms and other variables that aren’t always clear during a single visit.
This is just as it sounds — a plan for what the practitioner will do to treat the client’s concerns. However, the plan section of SOAP should not replace a treatment plan, in the SOAP context, plan is going to be a shorthand of the actions the practitioner will take to help the patient. If you want to read more about how to write great mental health treatment plans, be sure to check out our other post on the topic!
While there are a variety of progress note formats for behavioral health, the SOAP is a tried-and-true tool that makes it easy to document the essentials of a case.