SOAP Notes [2023 Update]
What are SOAP Notes?
SOAP Notes are a common practice for how therapists record information about their patients and their therapy sessions. If you are a school administrator or new therapist, you may not know what this acronym stands for. SOAP Notes stands for Subjective, Objective, Assessment, and Plan. Below is a quick breakdown of what gets recorded in each section, or if you are a visual learner, click on the video below.
The clinician records their impressions or any specific information reported by the student at the beginning or during the therapy session. It typically includes details about the student’s current condition, symptoms, concerns, and any information relevant to their therapy session that may not be quantifiable. It’s basically a description of the patient’s status from the therapist’s perspective. This area is also where the clinician reports things like technical issues (for online services) or if the student had to leave early.
All pertinent measurable data from the therapy session goes here. The therapist records the short-term goal percentages and things like the number of incorrect or correct items the child did during the session. In short, this is the place where information on progress goes. This includes measurable data, such as specific assessment results, test scores, vital signs (if relevant), and any other quantitative data that can be used to track progress or changes in the student’s condition.
This should include the clinician’s analysis of how the child did during the session. This is where they make clinical judgments about the patient’s progress, their response to therapy, and their overall condition. It may include diagnostic impressions, treatment effectiveness, and future goals for the patient. If the therapist has had previous interactions with the student, it can include how the current interaction compares to previous sessions. The therapist may also document how much assistance the child needed during the therapy session.
The plan section outlines the therapist’s plan of action based on their assessment. It includes the specific interventions, strategies, and goals for the patient’s future therapy sessions. The therapist outlines the course of services for future sessions. I.E., for Speech and Language Therapy, if the child has been working at a word level and will move up to working at a phrase or sentence level. This area may also include information about assigned homework.