How to Write SOAP Notes – for Mental Health Professionals

Documenting your patients’ progress is a big part of any mental health professional’s role. This helps you keep track of your clients’ treatment so you can provide the highest quality of care. SOAP notes also keep you compliant with record keeping guidelines and help protect you if your work needs to be reviewed at a later date. Having up to date records means that if you need to refer your patient to other healthcare providers, all the information they need is on hand, and your client can continue their treatment with the minimum of disruption.

Many mental health practitioners use a soap note style format to make and maintain accurate, clear records of their clients’ sessions.

What are SOAP notes?

SOAP is an acronym – it stands for:

• Subjective – the information from the client that they share in the session. This might include any medical or personal issues affecting the client, for example if they have any present illness that may affect their mental state.
• Objective – more factual information like the client’s diagnosis, appearance, mood and symptoms. You may want to include things like body posture, body language, eye contact and anything else of note about the clients’ appearance including their diagnosis and family history if relevant.
• Assessment – your assessment of the client’s mood, progress, any risks and anything else you noticed in the session. Your clinical reasoning behind any differential diagnosis or other assertions.
• Plan – next steps for your client, including any homework, consultations with allied healthcare providers, attending group therapy sessions or anything else that’s relevant.

Staying consistent with your SOAP notes can help you maintain a high standard of care for your clients, and ensure any other healthcare providers you’re working with have access to the most clinically relevant data at all times.

Mental health SOAP notes – the benefits

There are a number of benefits to using the SOAP format to keep your medical records up to date. These include:

• Effective and efficient diagnosis. By keeping records of your clients’ symptoms, behaviours and other relevant factors, you can make a more accurate diagnosis, and keep an eye on the vital signs that might necessitate a diagnostic review.
• Track a patient’s status and outcomes. Through regular progress notes, you can get a picture over time of how a patient is responding to a particular treatment so you can see what’s working and what might need adjusting.
• Provide consistency of care. If you’re working with other medical professionals, it’s important that everyone is kept in the loop. With thorough medical notes, you can hand over your patients to other practitioners with the minimum of disruption.

How to write quality SOAP notes

If you want to improve your note taking abilities, there are a number of SOAP note evaluation tools you can use. We’ve also put together a few tips to help you make sure your SOAP notes do the job they’re intended to do:

• Keep the language professional. You don’t know who might be reading your notes in the future, so make sure the language is professional and clear. Using colloquialisms, slang and spelling and grammar mistakes can impact the credibility of your notes, which could be a problem if other healthcare professionals are reviewing them in the future.
• Stay objective and clinical. Your notes should remain free from bias and personal judgements about your clients. Keep them free of assumptions, and stick with the facts. Any statements you do make that could be seen as subjective should be backed up with evidence where possible.
• Make time to update them regularly. If you don’t regularly put aside time to update your SOAP notes, they can very quickly pile up. By building time into your day to update your notes, you can keep on top of them while ensuring the session is still fresh in your mind.
• Double check the details. It’s important that your SOAP notes are accurate as they may be relied on in the future. It’s always a good idea to take some time after you’ve written them to double check any dates, times and other details to ensure everything is accurate.

Keeping accurate records is a core part of any mental health professional’s job. The SOAP methodology helps practitioners write and maintain up to date notes on their clients. Once you understand the format, SOAP notes are a great way to stay on track and protect yourself in the event of a review.