What are SOAP Notes in Counseling? (incl. Examples)

soap notesHow do doctors or therapists track what is happening with a patient or client from one visit to the next?

How do these professionals communicate this information with other professionals also working with the patient or client?

Years ago, this type of communication was not easy. It often meant that a patient or client had to remember from visit-to-visit what they said to one doctor, and then to another.

Now, medical professionals use SOAP notes for this purpose. This type of note-taking system offers one clear advantage: Consistent, clear information about each patient or client during each visit to a provider. When the providers are part of the same group, this information can be easily shared.

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What are SOAP notes?

Professionals in the medical and psychological fields often use SOAP notes while working with patients or clients. They are an easy-to-understand process of capturing the critical points during an interaction. Coaches also can make use of SOAP notes, but with some adaptations.

SOAP notes are structured and ordered so that only vital and pertinent information is included. Initially developed by Larry Weed fifty years ago, these notes provide a “framework for evaluating information [and a] cognitive framework for clinical reasoning,” (Gossman, Lew, & Ghassemzadeh, 2020).

SOAP notes are primarily the realm of medical professionals; however, as you continue reading, you will see examples of how you might adapt them for use in a coaching session.

To begin, the acronym stands for:

 

Subjective

During the first part of the interaction, the client or patient explains their chief complaint (CC). There might be more than one, so it is the professional’s role to listen and ask clarifying questions. These questions help to write the subjective and objective portions of the notes accurately.

The descriptor ‘subjective’ comes from the client’s perspective regarding their experiences and feelings. It might also include the view of others who are close to the client.

An example of a subjective note could be, “Client has headaches. Client expressed concern about inability to stay focused and achieve goals.”

Another useful acronym for capturing subjective information is “oldcarts” (Gossman, Lew, & Ghassemzadeh, 2020).

  • Onset: When did the CC begin?
  • Location: Where is the CC located?
  • Duration: How long has the CC been going on for?
  • Characterization: How does the patient describe the CC?
  • Alleviating and Aggravating factors: What makes the CC better? Worse?
  • Radiation: Does the CC move or stay in one location?
  • Temporal factor: Is the CC worse (or better) at a certain time of the day?
  • Severity: Using a scale of 1 to 10, 1 being the least, 10 being the worst, how does the patient rate the CC?

Think back to when you have had an appointment with a doctor. How many of these questions did your doctor ask? Chances are, they asked all of them. These questions are part of the initial intake of information and help the doctor or therapist, assess, diagnose, and create a treatment plan.

A coach can easily adapt this method to their sessions and exclude whatever does not apply.

For example, a life coach may not need to know or ask about location unless the client indicates that every time they are in a particular spot, they notice X. Here the idea is shifted from a location in the body to a location in the environment. The coach also might not need to ask about radiation.

 

Objective

The professional only includes information that is tangible in this section. In a clinical setting, this might be details about:

  • Vital signs
  • Physical exam findings
  • Laboratory data
  • Imaging results
  • Other diagnostic data
  • Recognition and review of the documentation of other clinicians

A clinical example is, “Patients heart rate is X.” “Upon examination of the patient’s eyes, it was found that they are unable to read lines X and X.”

In a coaching situation, a coach might include some of this information, but it depends on why the client is seeking assistance from the coach, and what type of coaching is done. For instance, a health or fitness coach might want to note diagnostic details like vital signs before, during, and after exercise.

Most coaches do not talk in terms of symptoms or signs, but if you happen to do so, then it is important to understand this distinction:

Symptoms are what the person tells you is going on physically, psychologically, and emotionally. They are the client’s subjective opinion and should be included in the “S” part of your notes.

Signs are objective information related to the symptoms the client expressed and are included in the “O” section of your notes.

Using the example from earlier, a coach might determine that the “S” is the client expressing concern over an inability to complete tasks and achieve a larger goal. The “O” is their observation that the client has no time-keeping devices.

After further discussion, it is discovered that the client does not plan their day with any structured tool. They use Post-it notes as reminders. Each of these small details might relate to the CC — an inability to stay focused and complete goals.

On the other hand, a medical doctor would assess the headache issue and test the person’s eyesight, especially if the patient does not already wear glasses.

The doctor might also explore whether the patient has ADD/ADHD because the CC mentions “an inability to focus and achieve goals.”

 

Assessment

In this section, the professional combine what they know from both the subjective and objective information. Here, the therapist or doctor identifies the primary problem, along with any contributing factors.

They also analyze the interaction between problems, as well as any changes to the problems. When finished, the clinician has a diagnosis of the problem, a differential diagnosis (other possible explanations), discussion, and a plan.

Coaches do not “diagnose” in the traditional sense. Their role is generally one of assisting a client in seeing what they typically already know, but with greater clarity, and perhaps, renewed purpose.

 

Plan

A plan is where the “rubber meets the road.” Working with the client or patient, the clinician creates a plan going forward. The plan might include additional testing, medications, and the implementation of various activities (counseling, therapy, dietary and exercise changes, meditation.)

In a coaching relationship, the coach works with the client to create realistic goals, including incremental steps. This plan includes check-in points and deadlines for each smaller goal and the larger one. The coach might assign “homework” just as a therapist would. Often the homework offers opportunities for self-reflection. It also provides practice and acquisition of a new skill.

There are other considerations and inclusions used in the medical field. For additional details, read SOAP Notes. Gossman and colleagues (2020) also point out several limitations regarding the use of SOAP notes.

Among these are:

  • The order places the less essential details at the top. It forces the clinician to lose time scanning for the necessary information during subsequent visits.
  • There is no section addressing how conditions change over time.
  • There also is no assessment area for how the plan is working.

 

Why are SOAP Notes Important?

making soap notesCynthia Moreno, executive director of the Association for Addiction Professionals (NAADAC), has highlighted the importance of quality SOAP notes for more than forty years.

At a 2016 NCRG Conference on Gambling and Addiction, she covered this, and the elements of good documentation.

According to Moreno, these include, but are not limited to:

  • Use of direct quotes from the patient or client
  • A distinction between facts, observations, hard data, and opinions
  • Written in present tense, as appropriate
  • Is internally consistent
  • Provides relevant information with appropriate details
  • Organized, concise, and reflect the application of professional knowledge

SOAP notes offer concrete, clear language and avoid the use of professional jargon. They include descriptions using the five senses, as appropriate. Value-heavy terms also are avoided. Impressions made by the clinician are labeled as such and based on observable data. Written documentation is about gathering the facts, not evaluating them.

Documentation protects the medical and therapeutic professionals while also helping the client. Clear notes communicate all necessary information about the patient or client to all of the people involved in the person’s care. SOAP notes facilitate the coordination and continuity of care.

 

Writing your SOAP notes

The primary thing to keep in mind is that SOAP notes are meant to be detailed, but not lengthy. They are a clear and concise record of each interaction with the patient or client.

Following the format is essential, but it is possible to reorder it so that the assessment and plan appear at the top (APSO). Doing this makes it much easier to locate the information you might need during future meetings or appointments.

The following video by Jessica Nishikawa provides additional information regarding why SOAP notes are used, by whom, and how to use them.

 

2 SOAP Notes Examples

Your client Tom Peters met with you this morning. Your notes are as follows:

Session date:
Type of session: Group or individual
Time of session:
Client’s Name:
Your name:

S: “They don’t appreciate how hard I’m working.”
O: Client did not sit down when he entered. Client is pacing with his hands clenched. Client sat and is fidgeting. Client is crumpling a sheet of paper.
A: Needs ideas for better communicating with their boss; Needs ideas for stress management.
P: Practice Conflict Resolution scenarios; practice body scan technique; Go for a walk during lunch every day for one week.

Your client Rosy Storme met with you this afternoon.

Session date:
Type of session: Group or individual
Time of session:
Client’s name:
Your name:

S: “I’m tired of being overlooked for promotions. I just don’t know how to make them see what I can do.”
O: Client is sitting in a chair, slumped forward, and burying her face in her hands.
A: Needs ideas for better communicating her ideas with her boss; Needs ideas for how to ask for more responsibility; Needs ideas for tracking her contributions.
P: Practice Asking for What You Want scenarios; Volunteer for roles within the company that are unrelated to a current job; Brainstorm solutions to problems employer faces.

 

3 Useful Templates

Numerous websites are offering free templates. Most are designed for use in the medical professions, including client-centered therapy and counseling. Here are three templates you can use for a medical visit, therapy, or coaching sessions.

We’ll show you a medical SOAP note, and will provide two PDF examples for therapists and coaches.

 

1. SOAP Note for Medical practitioners:

Medical SOAP Notes

 

2. SOAP Note for Counseling Sessions (PDF)

3. SOAP Note for Coaching Sessions (PDF)

 

A Take-Home Message

Whether you are in the medical, therapy, counseling, or coaching profession, SOAP notes are an excellent way to document interactions with patients or clients. SOAP notes are easy-to-use and designed to communicate the most relevant information about the individual. They also can provide documentation of progress.

For clinical professionals, SOAP notes offer a clear, concise picture of where the client is at the time of each session. They contribute to the continuity of care and are a tool for risk management and malpractice protection. For the client, they provide documentation of their problem, diagnosis, treatment options, and plans.

What is your experience using SOAP notes? How have you applied them to your coaching practice?

We hope you enjoyed reading this article. Don’t forget to download our 3 Positive Psychology Exercises for free.

If you wish for more, our Positive Psychology Toolkit© contains over 300 science-based positive psychology exercises, interventions, questionnaires, and assessments for practitioners to use in their therapy, coaching, or workplace.

  • Care Cloud (n.d.) Free SOAP note template. Retrieved March 6, 2020, from https://www.carecloud.com/continuum/free-soap-note-template/
  • Gossman, W., Lew, V, & Ghassemzadeh, S. (2020 January). SOAP notes. StatPearls Publishing. Retrieved March 6, 2020, from https://www.ncbi.nlm.nih.gov/books/NBK482263/
  • Nishikawa, J. (October 17, 2015). SOAP notes [Video]. YouTube. https://youtu.be/9TZqTtbBVXc
  • Template Lab (n.d.). 40 fantastic SOAP note examples and templates. Retrieved March 6, 2020, from http://templatelab.com/soap-note-examples/#SOAP_Note_Templates
  • Tuohy, C.M. (2016, September 25-26). Foundations of addiction treatment [Conference session].17TH Annual NCRG Conference on Gambling and Addiction, Las Vegas, NV. http://www.evergreencpg.org/media/Focus_on_the_Future/NW_Gambling_Conference_-_Cynthia_Tuohy.pdf

About the Author

Kori D. Miller, MA, is a habit change aficionado, facilitator, and coach. Kori loves helping others achieve their goals one bite-size step at a time. She completed graduate-level coursework in positive psychology through the University of Missouri-Columbia and is completing a master's program in Educational Psychology with a specialization in neuropsychology.

Comments

  1. Lisa Holden Rovers

    Thanks for sharing this resource! I have heard of SOAP notes from a “scriptures study” practice, and have been using it in my own learning – e.g. I read a chapter in a book and reflect on it – What did it SAY? What did I OBSERVE from that? How does it APPLY to my life now? What’s a PRACTICE I want to put in place now. This gives me a whole new way to look at it in my coaching practice. Thank you.

    Reply

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