As Counselors continue to meet with clients on their caseload in, we need to document the time and length of the meetings, as well as the content of the discussion following the SOAP Method.
- Subjective: The client's perspective regarding their experience and perceptions of symptoms, needs, and progress toward treatment goals. This section often includes direct quotes from the client/ patient as well as vital signs and other physical data.
- Observation: Your observed perspective as the practitioner, i.e., objective data ("facts") regarding the client, like elements of a mental status exam or other screening tools, historical information, medications prescribed, x-rays results, or vital signs.
- Assessment: Your clinical assessment of the available subjective and objective information. The assessment summarizes the client's status and progress toward measurable treatment plan goals.
- Plan: The actions that the client and the practitioner have agreed upon to be taken due to the clinician's assessment of the client's current status, such as assessments, follow-up activities, referrals, and changes in the treatment.
This article describes how to create a SOAP Note.
From the Client's Contact Record
1. Click Client Notes.
2. Click New Note.
3. Type the Subject.
4. Select the Type of Interaction.
5. Input the correct Session Start Time.
6. Input the Length of Time (Minutes) you met with the client.
Length of time will automatically set to 50 minutes as the default for Counseling sessions. Your Session End Time will adjust according to the length of time.
7. Scroll down.
8. Look through the list of Activities Performed and select the correct activities.
9. Click and drag the activities into the box on the right or push the right arrow to move them over.
10. Click Next.
If you also have files you also need to upload to the Client's Contact Files or to their Clinical Files, you can do so right from the note.
11. Select whether you need to Create Service Deliveries after you complete your note.
12. Scroll Down.
13. Type the Subjective Summary.
14. Type your Observed Behaviors.
15. Select the Assessment for Risk.
16. Indicate As evidenced by:.
17. Type the Assessment Narrative.
18. Type the Assigned Client Homework.
19. Type the Planned Clinician Follow-up.
20. Scroll down.
21. Type the General Note.
22. Click Next.
Your note has now been created. You are also able to relate the note to more records and add files as you create your note.
From the Client's Program Engagement
1. Click New Note.
2. Type the Subject.
3. Select the Type of Interaction.
4. Input the correct Session Start Time.
5. Input the Length of Time (Minutes)you met with the client.
Length of time will automatically set to 50 minutes as the default for Counseling sessions. Your Session End Time will adjust according to the length of time.
6. Scroll down.
7. Look through the list of Activities Performed and select the correct activities.
8. Click and drag the activities into the box on the right or push the right arrow to move them over.
9. Click Next.
If you also have files you also need to upload to the Client's Contact Files or to their Clinical Files, you can do so right from the note.
10. Select whether you need to Create Service Deliveries after you complete your note.
11. Scroll Down.
12. Type the Subjective Summary.
13. Type your Observed Behaviors.
14. Select the Assessment for Risk.
15. Indicate As evidenced by:.
16. Type the Assessment Narrative.
17. Type the Assigned Client Homework.
18. Type the Planned Clinician Follow-up.
19. Scroll down.
20. Type the General Note.
21. Click Next.
Your note has now been created. You are also able to relate the note to more records and add files as you create your note.
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