Do you know what SOAP notes are?
Would you like to know how it’s written? Then, stick to this page until the end of our discussion. We’ll tell you what these notes are all about.
In addition to that, we’ll give you SOAP note examples for social workers. After reading through it, you should be able to document your client’s progress.
SOAP Note Social Work Examples
SOAP notes are vital in patient care.
It helps healthcare practitioners, including social workers, capture specific client information. Moreover, it reduces administrative time and improves communication between all parties involved in patient care.
The case notes also record each patient and social worker interaction. That way, it will ensure they get the help they need.
Is SOAP Note Essential?
Of course, this framework is very critical in the healthcare industry.
As highlighted above, it’s a clinical way for healthcare providers to simplify and organize patient information. The note is essential as it helps keep track of patients’ treatment progress in a consistent and structured way.
Moreover, it helps medical practitioners use clinical reasoning to assess, diagnose, and treat clients using the presented details. It can serve as a communication tool for different health experts.
A quality SOAP note includes a template structure, like a checklist. It enables clinical workers to capture the details of clients consistently while providing an index to retrieve their medical history.
What a Good SOAP Note Entails
Of course, you know what this therapy note is all about. But do you know how to write one?
You must know how to establish an excellent SOAP note. Not only will you keep accurate details about your client, but it will also deliver the best treatment plan.
To get the most out of SOAP progress notes, keep them to 1.2 pages. Also, focus on the most essential details that need to be recorded.
While you do that, avoid personal judgments and use “good” or “bad” to describe behavior. Also, make the content unique and don’t repeat prior session notes.
Finally, you’re to make statements supported by measurable or observable information. Don’t make it hard to read, but rather make it legible.
Introduction to Social Work SOAP Notes
The term SOAP in this context stands for “Subjective, Objective, Assessment, and Planning.” It’s a framework designed for recording details related to patient interaction in a meeting or session.
With this framework, social worker case notes can easily be made clear. That’s because some essential information may need to be included.
Let’s briefly look at the SOAP note templates for social workers.
The subjective part of SOAP notes records the patient’s description of situations.
These include their chief complaints, needs, experience, and perception of symptoms. Moreover, it records verbatim client quotes, progress toward treatment goals, thoughts, concerns, and actions.
Furthermore, the subjective data collects input from family members, caretakers, and parents. That’s in the case of a family group session, child or adolescent.
While writing a personal note, there are specific contents you should leave out. First, you should avoid including statements without supporting facts.
The details you’ll provide should be relevant, and the report must be from the client, family, or teachers. this
This section is intended to be completed by a social worker or healthcare professional.
The report should contain factual data that can be quantifiably surveyed. In other words, the details should be based on counselor observation in measurable and observable terms.
Such details include body language, facial expression, physical appearance, test results, and activities. Data on elements of mental health status, medication prescribed, and screening tools can also be recorded.
In the case of coaching, the coach may include some vital details about the client’s fitness. However, the information to jot down depends on why the client is seeking assistance from the coach.
Specific details should be excluded from objective SOAP notes.
They include personal judgment, labels, general statements without supporting data, and value-laden language. Avoiding opinionated views, assumptive reports concerning human behavior, and more would be best.
Assessment in SOAP notes combines both subjective and objective data.
In other words, it evaluates the client’s default and existing treatment. The social worker will identify the primary problem along with other contributing factors.
Some of the details in this section show that the client continues to experience family-related stressors and exhibits signs of moderate depression.
You may also include the client who appears to continue experiencing anxiety or whose anxiety has increased in severity and appears to meet the criteria for GAD.
However, certain statements should be excluded from the assessment section. One is the repetition of the previous report in the S.O. sections.
You’re to only focus on progress, regression, and plateaus in client progress.
Here, you’ll outline the action plans you design for the client’s treatment. You must also focus on your next steps for the upcoming session.
Additionally, you’ll need to stay aligned with your overall treatment plan. While doing that, you’re advised not to reinstate it in full in this section.
You may include things both parties have agreed upon, client progression/regression, and implementation.
You can also provide notes aligning with the assessment and direct, nutritional, and medical attributes contributing to the client’s therapeutic goals.
Meanwhile, specific contents should be excluded from this section. They have unrealistic and immeasurable goals to accomplish before the client’s next session and restate the overall treatment plan.
Examples of SOAP Notes for Social Workers
Here are some examples for those who don’t know how to write a SOAP note: This should help you keep records of your client’s treatment process and progress.
Let’s say your client Mary Stones met with you this morning; your notes should be written as follows:
- Subjective: “They don’t appreciate my hard work.”
- Objective: The client sat down when she entered. The client sat down and wasn’t fidgeting. The client is crumpling a sheet of paper.
- Assessment: Need ideas for better communication with their boss. Need ideas for stress management.
- Planning: practice conflict resolution scenarios. Practice body scan technique. Stay out for a walk during lunch every day for two weeks.
If client John Wick met you this afternoon, your SOAP note should be written as follows:
- Subjective: the client at the café stated, “My guardian didn’t like me, so I left, and now I struggle to survive.”
- Objective: The guardian didn’t call to find the child. The teen is 17 and homeless. I left home four months ago. The PHQ-9 score was 14 for moderate depression.
- Assessment: The best case will be the guardian or parent reunification. However, the teen needs to have depression and negative thoughts addressed through therapy first.
- Plan: Have the teen handled by a licensed clinical social worker and begin a short-term therapy plan. Contact the guardian and recommend mediated reunification so the teen remains home.
A client can meet with you regarding his daughter’s bad behavior. This is how to write SOAP notes in that regard.
- Subjective: Cole states that his son Peter hardly stays in the house. Peter didn’t attend last night’s dinner. He left this morning without any notice.
- Objective: Peter doesn’t like it in the house. Peter absconded from last night’s dinner and left this morning without notifying anyone. Peter and his parents are constantly in battle.
- Assessment: Peter needs to progress in his plan; serious adjustments are recommended now.
- Planning: Peter was asked to stay home for at least 20 hours and be consistent for four weeks. Peter will be meeting with a counselor twice a week.
Using SOAP Notes with Your Practice Management System
Do you know how to use a SOAP note in your practice management software? Of course, you can. Applications like SimplePractice come with easy and secure therapy, progress, and SOAP notes.
Other note-taking templates are also built into the platform. This ensures fast and simple access to your notes and fills them out after each session.
If SOAP notes aren’t already included in your EHR, you can get a template for one here. Recall that the purpose of your SOAP notes is to record your discoveries for future reference.
Using the industry-leading standard format in your practice would be beneficial.
However, it can be helpful if you’ve thought about moving to a fully integrated, HIPAA-compliant practice management system. To provide you with everything you need to organize your note-taking process, we suggest SimplePractice.
You can select a template for a SOAP note from the extensive template collection. Utilize the “load previous note” option to update your notes effortlessly during each session.
You can email your clients follow-up details about your sessions via the client site.
Perks for Writing a SOAP Note
Writing a SOAP note comes with many advantages.
If you’ve been underestimating its importance, know it can be a game-changer in your medical practice. In this section, we’ll outline some perks so you can see reasons to adopt this method of record-taking.
A SOAP note improves note-taking efficiency and helps medical providers formulate treatment strategies. It also ensures the completeness of progress notes, facilitates communication with other team members, and organizes patient session documentation.
It also reduces miscommunication between healthcare experts and is used in social and medical communities.
SOAP notes typically constitute the client’s statement about appropriate behaviors or status. It also includes observable, measurable, quantifiable data and analysis given by the client.
If you’re wondering how to write one, here are some excellent examples. We hope they guide you to become an expert in writing such notes.