The SOAP (subjective, objective, assessment, and plan) note is one of the most important reports that medical transcription companies help physicians document. In mental health, writing clear and concise SOAP notes is essential to record the patient’s continuum of care. Providers use SOAP notes to monitor and document patient progress, record services, and communicate patient information to other professionals.
While there have been debates about the relevance of the SOAP notes in the EHR due to the increased complexity of medical care, this documentation method continues to be useful in the current context with appropriate EHR integration. Mental health transcription services are a practical option to maintain timely, effective and meaningful SOAP medical notes in the EHR.
SOAP Note Structure in Mental Health
The elements in acronym SOAP are Subjective, Objective, Assessment and Plan. Here are the main aspects that need to be included in a SOAP note in behavioral health:
Subjective – Documentation under “Subjective”, the first heading of the SOAP note describes the patient’s personal views/feelings of a patient or comments of a person or persons close to them. In addition to the chief complaint and present symptoms, the physician should document medical and family health history and changes in functioning.
Objective – This section covers the objective data collection during the patient encounter such as vital signs, physical exam findings, laboratory test and imaging results, and other diagnostic information. It also includes recognition and review of the documentation of other clinicians. In the mental health assessment, the objective part of SOAP notes relates to how the body functions and assesses neurological functioning with the Mental Status Exam (www.icanotes.com).
While symptoms are documented in the Subjective section, signs should be noted in the Objective section. Symptoms are the patient’s description of the condition while signs are the objective evidence of the symptom that is observed. For example, if the patient reports feeling agitated, the signs may include racing pulse, sweaty palms, shaky hands and dry mouth. The patient’s current medications (including the medication name, dose, route, and how often) and allergies may be documented in either the Subjective or Objective sections.
Assessment: This section contains the physician’s impressions and interpretations based on the information documented in the Subjective and Objective sections. The aim of the assessment is to arrive at a diagnosis (problem). However, the initial visit may not include a diagnosis, especially if the condition is complex and needs more subjective and objective data to identify the problem. All possible diagnoses – differential diagnoses – should be listed in order of importance, from most to least likely, along with the decision-making in the diagnostic process. The Assessment should include only the most pertinent information.
Plan: The Plan brings the above three sections together to formulate the treatment plan and any additional treatment steps. It allows future providers to understand what needs to be done next. The Plan should include action to be taken for each diagnosis. ICA Notes lists the contents of the Plan as follows:
- The treatment administered in each session and the rationale for it
- The patient’s immediate response to the treatment
- Date of next scheduled visit
- Any instructions given to the patient
- Goals and outcome measures for new problems/problems being re-assessed
If the patient has multiple concerns (such as depression and substance abuse) there should separate plans for each diagnosis.
An MDEdge Psychiatry article published 2019 April makes 6 recommendations for better organizing the P in a SOAP note in mental health care. According to the article the goal should be to organize the plan in a way that it is systematic and relevant across various psychiatric settings, such as outpatient, inpatient, emergency room, jail, pediatric, geriatric, addiction, and consultation-liaison. The author recommends a Plan format that has six categories: Safety concerns, collateral, medical, Nonpharmacologic interventions and assessments and nonpharmalogic interventions that would be useful, and time frame for disposition/follow-up, based on whether outpatient or inpatient.
According to the American Academy of Child and Adolescent Psychiatry, about one in five children have significant mental health challenges. One main challenge is ensuring consistency and continuity of care for those with mental health and substance abuse issues. There is also a shortage of providers to meet the needs of the population. While public awareness of mental health is growing, a common problem is the people who need mental health services often face difficulties in getting timely and effective treatment. Most individuals do not acknowledge that they have a mental illness and even if they recognize the problem, there is potential stigma associated with seeking mental health treatment.
Good documentation, including proper SOAP information, helps improve quality of care. As they deal with these challenges of managing patients, physicians can rely on a medical transcription service provider specialized in psychiatry transcription for documentation support.