The acronym SOAP stands for Subjective, Objective, Assessment, and Plan. A SOAP note conveys session information that can be used in conjunction with other treatment providers in regard to a patient’s plan of care. Healthcare is increasingly a team approach so communication must be clear and collaborative while keeping HIPAA laws in mind. In Catalyst, SOAP notes are organization-specific, for example, some organizations refer to them as progress notes, session notes, etc. It is essentially a clinical document that documents a billable service, such as 97153 (1:1 Adaptive behavior treatment by protocol).
SOAP notes maximize the value of your case notes by organizing perceptions, observations, metrics, and analysis in order to meet the treatment needs of clients. These progress notes are included in the client’s treatment record and can be shared with the interdisciplinary team.
SUBJECTIVE is qualifiable or descriptive information expressed by the client or the client’s family, that is based on revelation or observation. This can include patient quotes, attention, and engagement level.
OBJECTIVE is quantifiable or measurable information. This would include the specific objectives that are used to meet goals for such things as IEPs, or treatment plans.
ASSESSMENT is the section where you, as the provider, assess and document your synthesis of the subjective and objective sections of the SOAP note. This can include the effectiveness of treatment or its inefficacy.
PLAN is for writing down what will come next in your client’s plan of treatment. You will include any short or long-term goals, frequency, and length of therapy and any plan of treatment changes.
SOAP notes are meant not only to organize your client session but to create actionable treatment plans that can be shared with other members of the interdisciplinary team. Keep your SOAP notes fresh and clean.
Why SOAP Notes are Important
The SOAP notes you take to document each ABA therapy session can also be used to substantiate billing claims sent to insurance providers. They also communicate to your client’s interdisciplinary team your rationale for ongoing services. SOAP notes are also important because observations aren’t always subjective. Some observations can be measurable. For instance, a diagnosed narcoleptic client falls asleep for 10 minutes in the therapy session. You wouldn’t just assume that the client was tired when you should have it in your team notes that your client is narcoleptic which would lead you to time the amount of sleep during your session. This is why taking good SOAP notes is imperative across the board.
What it IS
What it ISN'T
SOAP Notes in Catalyst (Next Steps)
- Admin Actions