This is the second post in a series that highlights standardized formats for your clinical notes. The series began here.
Probably the most common form for standardizing your clinical notes is SOAP notes. It’s likely that you learned how to document in this standardized form early on in your training as a mental health provider and you may have continued to use this format up until now. SOAP is a mnemonic that stands for Subjective, Objective, Assessment, and Plan.
In this format, Subjective includes only the client’s subjective information. Often this looks like a summary statement or direct quote from the client.
The Objective portion of your clinical note is observable data or information that coincides with the subjective statement. Typically this includes the client’s body language and affect.
The Assessment is your professional and clinical judgment based on the aforementioned Subjective and Objective statements.
The Plan includes your intentions for future clinical work, any homework that was given, any referrals / interventions made, and any follow up needed or completed.
Many agencies and organizations use SOAP notes as their standard format for note taking. Although it can be awkward and does not always easily permit the inclusion of data that you might feel is pertinent, SOAP continues to be a commonly accepted format for documentation of clinical notes.
Tomorrow I’ll talk to you about DA(R)P notes.
Nicely explained.
Thanks, Brenda!