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SOAP Notes for Progress Documentation

The document outlines the structure and importance of SOAP notes in healthcare documentation, emphasizing their role in facilitating communication among professionals. It details the components of SOAP: Subjective, Objective, Assessment, and Plan, providing guidelines on how to document each section effectively. Additionally, it includes references for further reading on psychological assessment and therapy practices.

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23 views15 pages

SOAP Notes for Progress Documentation

The document outlines the structure and importance of SOAP notes in healthcare documentation, emphasizing their role in facilitating communication among professionals. It details the components of SOAP: Subjective, Objective, Assessment, and Plan, providing guidelines on how to document each section effectively. Additionally, it includes references for further reading on psychological assessment and therapy practices.

Translated by

ScribdTranslations
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
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WRITING OF John R.

Roman Alamo
MS/MHC

NOTES OF CPSY 679


Dr. Nilde Cordoliani
PROGRESS
INTRODUCTION
In health care, the medical record is both
a health document as legal.
SOAP notes are the most popular way to
documentation of medical procedures nowadays.
Invented by Dr. Lawrence Weed
SOAP notes are designed to provide a method of
problem-oriented medical documentation and to create a method
of fluid and consistent communication between professionals
doctors.

SOAP refers in English to "Subjective, Objective,


Assessment and Plan
HOW TO PERFORM A
PROGRESS NOTE?
The format of a progress note will depend on the
place where you are offering the services...

SOAP format

S. Subjective
O. Objective
A. Assessment
P. Plan
SUBJECTIVE
SUBJECTIVE
In this part, the first verbalization is documented that
The patient was examined. Reason for referral/ main complaint.

Ex.
I feel depressed, that's why I wanted to seek help.
I am fine
I am still the same
HOW DO YOU
DOCUMENT?
He is going to put the patient's verbalization literally between
quotation marks.

You can use words like:


Patient reported, indicated, ...

Ej.
I feel depressed, that's why I wanted to seek help.
patient reports a low mood, reason for the
who seeks psychological help.
I am still the same - The patient reports continuing with symptoms
of.....
I feel good. The patient reports being in good condition.
mood, compared to the previous week. (according to
apply)
OBJECTIVE
This part is extremely important, it must be documented.
in detail. The therapist is going to perform a state
mental and document it in all its parts.

APPEARANCE/ POSTURE.
E.g. A 26-year-old female adult patient, who
show an appropriate chronological age with his/her age
apparent. Looks well-groomed and dressed appropriately
for the occasion Thick body type. Shows a
tattoo on her neck with two hearts and some letters that
Until the end.
Maintains a normal posture.
OBJECTIVE
CONT.

Facies (Affection) and spirit

The patient verbalized feeling sad and hopeless;


shows a depressed face consistent with the state
of reported mood.
OBJECTIVE CONT.

State of consciousness.

The patient appears alert to the questions of the


therapist and the stimuli of their environment.

Orientation

The patient is oriented in all three spheres.


Evidenced by its ability to mention the
month, day, and year in which we are, place and number of
floor where it was located, in turn could say its
nombre completo, edad y ocupación.
OBJECTIVE
CONT.

Memory, Attention, Concentration, Thinking

The patient's attention and concentration are


decreased (moderately impaired,
(preserved).
When evaluating immediate, recent, and remote memory, the
patient was able to indicate the name of the therapist, the time of
the citation and mentioned in detail an event that occurred a long time ago
three years ago. His thinking process was logical,
organized and coherent. Its content of thought
revealed thoughts of sadness, anxiety, and death, after
the passing of her husband. The patient denied any ideas
suicides or homicides.
OBJECTIVE
CONT.

Language

The receptive and expressive language skills are intact.


the patient can understand and express their thoughts and ideas of
clearly as well as understanding what is being said.
Indicate speech rate.

Judgment / Introspection (insight)


The patient shows intact judgment evidenced by denying ideas,
suicidal and homicidal thoughts.
The patient's judgment is compromised evidenced by ...
The patient shows an ability for introspection as she was
able to recognize their mood and seek help.
ASSESSMENT /
EVALUATION
What did I value?

What did the patient indicate regarding the evaluation?


psychological?
What is relevant to establish my diagnosis?
Initial interview? - Follow-up appointment - ?
Resultados de pruebas psicológicas, administración de
inventories etc.
These results suggest X.....
Diagnosis …
Ej.
The patient requested psychological services verbally.
feelings of sadness after the death of her husband.
During today's intervention, the history was completed with
the patient
ASSESSMENT /
EVALUATION CONT.

Patient reported low mood, feelings


of disability, anhedonia, and difficulties in the
concentration, however at the time of the interview
the patient's concentration was pleasantly preserved.
Patient reports X... Information was collected and
complete X….

Examples...
I established rapport...

The patient was psychoeducated regarding their diagnosis and the


presented symptoms...
PLAN
Remember to take into consideration the previous note. That
demonstrate a logical sequence of what you are going to
performing with the patient.

1. Manage BDI and BAI to highlight feelings of


sadness. and to be able to confirm diagnosis.
2. Discuss with supervisor X…..
3. Collateral interview with X for the purpose of X….
4. Discuss and practice relaxation exercises to
decrease? Increase....
5. Verify the effectiveness of relaxation exercises
6. Monitor / requires follow-up ..........
PLAN CONT.

7. Identify automatic thoughts, emotions, etc.


[Link] automatic thoughts
9. Identify and modify intermediate beliefs,
core beliefs...
REFERENCES
Batista N (2010) Interview, Planning and Writing
Files Puerto Rico, Puerto Rican Publications
inc.
Corey G. (2013) Theory and Practice of Counseling and
Psychotherapy Canada, CENGAGE Learning
Lorenzo J. (2006) Fundamental Principles of the
Psychology Puerto Rico Publications
Puerto Ricans, inc.
Messer S. & Gurman A. (2011)Essential Psychotherapies
Theory and PracticeUSA, Guilford Press
Perpiña C. (2012) Manual of Psychological Interview
knowing how to listen, knowing how to ask Spain, Editions
Pyramid
Othmer E & Othmer S (2003)La entrevista clínicaEspaña,

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