The acronym SOAP stands for Subjective, Objective, Assessment, and Plan. Even though therapists don't usually use a traditional SOAP Note format, Catalyst refers to session or progress notes as SOAP Notes. 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.
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 |
|
|
Anatomy of a Catalyst SOAP Note
All SOAP Notes will start with the heading SOAP NOTE REPORT followed by the SOAP Note Header (see here for more information).
This will be followed by the sub-heading SOAP NOTE RESPONSES which will include all the default fields (Date, Start Time, End Time) and all fields that have been added to the SOAP Note template that is being used. See Create SOAP Note Template and SOAP Note Glossary for more information.
At the bottom of the SOAP Note, you will find a statement followed by BEHAVIOR DATA FOR SESSION and SKILL DATA FOR SESSION. Under each of these sections, the data you have collected during the time range entered on the SOAP Note will pull into the corresponding section. So, for example, if you take data on the App from 6:15 to 7:15 pm on 1/1/2020 and your Start Time, End Time and Date entered on the SOAP Note covers this time (exp. 1/1/2020 6 pm-7:30 pm), all the data you collected would pull into the note. If you collect data outside of the Date/Time range entered on the SOAP Note (exp. 1/1/2020 5 pm-6:10 pm), the information would not pull onto the note.
NOTE: Echoic and Anecdotal Target Types will not pull to your SOAP Note as they are not counted towards Mastery.
SOAP Notes in Catalyst (Next Steps)
- Overview
- Admin Actions
- Use
- Report