THERAPY NOTES
SOAP Notes
At Droste, we use the SOAP notes structure in TherapyNotes.
What is a SOAP note?
(Subjective Objective Assessment Planning) SOAP notes are intended to capture specific information about a client and certain aspects of the session. SOAP notes include a statement about relevant client behaviors or status (Subjective), observable, quantifiable, and measurable data (Objective), analysis of the information given by the client (Assessment), and an outline of the next course of action (Planning). All SOAP notes should be kept in a client’s medical record. You can find more info on SOAP notes HERE.
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Clients, chief complaint, presenting problem, and any other relevant information including direct quotes from the client, Any relevant personal or medical issues that may impact or influence the clients day-to-day routine, A complete account of the clients description of symptoms, Progress from the last encounter
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Physical, interpersonal, and psychological observations, Verbal nonverbal, Body posture, general appearance, affect and behavior when discussing certain topics or issues, nature of therapeutic relationship, strengths, mental status, ability to appreciate to participate in the session, responses to the process, written materials.
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Use professionally acquired knowledge to interpret the information given by the client during the session, implement critical knowledge and understanding, DSM/therapeutic model, identity, themes, or patterns. Update/include DSM criteria, observations exhibited by the client.
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Next steps for upcoming session, stay aligned with overall treatment plan, focus on things both parties have agreed to, note nutritional physical and medical attributes that will contribute to the clients therapeutic goals, note progress or regression. Client has made and treatment include implement implementation details ensure planning is aligned with assessment and direct.
Taking Session Notes in TherapyNotes:
From the client's record, click on the "Notes" tab to create session notes.
Select the appropriate note type (e.g., Progress Note, Psychotherapy Note).
Document the session details, interventions, client responses, and any other relevant information.
Save the note to the client's record.
Other Templates Include:
DAP notes
DAP stands for Data, Assessment, and Plan. DAP notes take the Subjective and Objective sections of a SOAP note and combine them into a single section: data.
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This could include:
Reason for the visit
Client presentation/appearance
Client mental status
Client reports of current symptoms or important events since the last session
Results of screening or other measures
Interventions applied in session
Client responses to interventions applied
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This could include:
How the client is progressing
How the client’s status relates to their treatment goals
How the client responded
Changes to the client’s diagnosis
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This section could include:
The date, time, and location of the next scheduled session
Homework assigned to the client
Referrals provided to the client
Consultation or other third-party contact planned by the clinician
Changes to the treatment plan based on the client’s progress so far
Additional steps related to the treatment that the client or clinician is expected to take
BIRP notes
BIRP note structure = Behavior, Intervention, Response, and Plan.
BIRP notes can make your documentation more efficient by boiling down each session to four key questions:
What’s the specific problem to be addressed in this session?
What did the therapist do about it?
How well did that work?
What comes next?
What’s the difference between BIRP notes and SOAP notes?
BIRP notes and SOAP notes are both meant to streamline the note-taking process. BIRP notes focus on describing a session’s theme and overall tone, as well as the behavior of your client, while SOAP notes aim to be more objective and document treatment outcomes and next steps