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What are SOAP Notes?
SOAP Notes are a way of recording medical or clinical information and notes through a common methodology of note-taking. Mental health providers will find SOAP notes beneficial for creating treatment plan documentation in particular.
SOAP notes can be used by many different providers across different medical disciplines, but for our purposes this template will work well within your mental health practice.
What does SOAP stand for?
Subjective, objective, assessment, and plan.
SOAP Notes Template Outline:
Subjective: SOAP Notes
Establish, refer to, or continue on their chief complaint and history of their present clinical situation.
Objective: SOAP Notes
Review the changes and findings of their new clinical situation as a result of your session together.
Assessment: SOAP Notes
A quick summary of their primary and secondary diagnoses. (Search diagnosis here)
Plan: SOAP Notes
Recommendations for future care.
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