Subjective Objective Assessment Plan
Subjective Objective Assessment Plan
Importance of SOAP Notes & Documentation:
We all know that one of the worst parts of being a therapist is all the documentation that comes along with it. This guideline is to make that process for session notes a little easier!
Deadlines:
Unfortunately, SOAP notes are due by the end of the session day - this is important for insurance & billing purposes, so please keep in mind that if you cannot write the note in the last 2-5 minutes of your sessions, it is expected to be completed at another point in time within the day.
Insurance:
If the insurance requests for SOAP notes, it is the Reception Team’s responsibility to combine session notes within the requested period of time to send to insurance.
It is the clinician’s responsibility to make sure that all notes are filled out.
Format:
The format does not have to be a long or extremely detailed. Simply state the subjective observations of the session (ex. presented with positive affect overall), objectives (ex. goals targeted with what activities), assessments (ex. accuracy of goals), and plan (ex. what to do next session).
Use the SimplePractice “Load last note” function in order to write efficiently.
Sample:
Malang was on time accompanied by his mother, Ms. Lynn. He presented with overall positive affect and participated well with reading (Three Little Pigs) and board game (Pop the Pig) activities for targeting the following goals:
Goals:
Malang will produce a narrative including at least 3/7 story grammar elements given orthographic cues across two consecutive sessions: 4/7 accuracy, (1/2)
Malang will answer yes/no questions regarding salient information from the reading activity with 80% accuracy given minimal (pause) cues across 3 sessions: 90% accuracy, (2/3)
Malang will use turn-taking language with 90% accuracy given moderate (phonemic) cues with 90% accuracy across 2 sessions: 60% accuracy, (0/2)
Plan: continue goals, read Peppa Pig due to strong request