Taking SOAP notes in mental health

Jun 8, 2021

If you operate a mental health clinic of any variety, it’s prudent to consider taking SOAP notes in mental health patient care.

Adopting SOAP notes during the course of patient care can revolutionise the way you operate. SOAP notes help you track a patient through your designated treatment plan and assess outcomes and progress.

If you’re not taking well structured notes in your treatment of mental illness, you run the risk of not accurately understanding your patient’s trajectory, symptom progression and treatment effectiveness.

In addition, by utilising the SOAP notes methodology, you’ll also be in possession of a set of notes that are easy to send to relevant health practitioners when referring a patient for further treatment.

What are mental health progress notes?

Mental health progress notes, including the SOAP format, are used to track the progress of a mental health patient in your care.

In contrast to ad-hoc note taking styles, SOAP progress notes will help you share patient data with other health professionals in an organised manner.

While mental health SOAP notes are primarily used to document patient observations, sessions and treatment, SOAP documentation also helps you progress a patient through the following workflow of practice management:

  1. appointment scheduling
  2. patient check-in and exam
  3. documentation of notes
  4. rescheduling
  5. medical billing

What are SOAP notes?

Before we get ahead of ourselves, we need to understand what SOAP therapy notes are.

SOAP stands for subjective, objective, assessment, and plan. By taking typed or handwritten notes according to each category of SOAP, you can better track and organise your patient care in a standardised manner.

The SOAP notes format is essentially a templated approach to documenting patient interactions and assessing their condition in a structured and repeatable way.

With the SOAP method, when you hold a patient session or examination you’ll take mental health progress notes using the following SOAP notes template structure:

(S)ubjective

A statement about client behaviour or current status.

The subjective section takes the form of a detailed set of notes, relying on patient self-assessment. Written in an interview format, you’ll often include questions you asked, and the patient’s responses in quotation marks. Take notes that pertain to:

  • chief complaint
  • current condition
  • symptoms
  • history
  • environment
  • activities

For example:

  • “When asked about sleep, Jenny stated that she was getting ‘probably less than six hours a of low-quality sleep per night’. We discussed sleep strategies and ways to remove stress.”

(O)bjective

Data that is quantifiable or measurable.

For the objective section, you will take fact-based notes regarding your own objective observations of the patient. You should include information such as:

  • physical appearance
  • demeanour and mood
  • body posture
  • mental status
  • strengths and weaknesses

For example:

  • “Andrew’s appearance was dishevelled; he was in a non-receptive mood and avoided eye contact. He was, however, alert and mentally sharp.”

(A)ssessment

Make patient assessment based on both your subjective and objective notes and your professional opinion.

By assimilating information from your S and O sections, you’ll interpret and assess the patient’s status to the best of your professional ability.

For example:

  • “John is displaying signs of depression and has continued to experience anxiety. His well-dressed and neat appearance indicates he is practicing good self-care.”

(P)lan

Outline your treatment plan and focuses for upcoming sessions.

In the plan stage, you’ll assess the current treatment plan and detail any changes you should consider. Long term goals should be a focus. You should include aspects such as:

  • what symptoms should be focused upon
  • treatment plan assessment
  • what will be the focus of the next session
  • what is and isn’t working

For example,

  • “I need to reassess how to best to treat Erin’s symptoms of depression and make self-care the focus of our next session.”

Why are SOAP notes important?

SOAP notes are important to not only record and evaluate your patient’s treatment and concerns, it does so in a way that is structured and dependable.

By following the same format every time, you can easily compare previous notes and sessions, be sure you didn’t miss any aspect of your patient evaluation and be able to share notes with other health professionals.

By standardising your patient notes and data, you’ll increase the usefulness and value of your patient records – bettering patient outcomes and treatment quality.

Should I use the SOAP format?

With SOAP being a well-recognised note taking standard, you could certainly do worse when it comes to patient documentation.

While you may choose to use an alternate note taking format, the advantages of mental health progress notes are undeniable.

As long as you’re using a standardised methodology of patient note taking, you’ll always have an accessible set of data you can use to deliver the best patient care and treatment plans possible.

Since it’s a widely understood format, taking SOAP notes in mental health is certainly something any practitioner should be consider.

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