The most conventional cause of sentinel situations in healthcare is poor communication. Communication problems between psychologists and psychiatrists can have life-threatening consequences. Hence, all clinicians should strive to master the ability to communicate medical information accurately, clearly, and succinctly in light of these scary outcomes.

Behavioral health care professionals should take notes when treating their patients to ensure quality care—especially when attending to mental health patients. About 70 million people in India have a mental illness, yet many do not have access to support or mental health treatment.

The good news is that most psychologists and psychiatrists are using our psychonline tools to create session reports to expand interaction and track patient progress and treatment.

Mastering the art of making concise, comprehensive, and informative reports for other professionals to use can take years. But what exactly are SOAP reports? 

Let’s look a closer look what Soap reports are and how to use them.

What are Soap Reports?

SOAP reports stand for Subjective, Objective, Assessment, and Plan and are a widely used method for medical documentation. They are entries that identify a client and specific aspects of the therapy session.

SOAP reports include relevant client status or behaviors (subjective), an observation, a quantitative measurement, an assessment of the information the client provided (assessment), and an outline of the following steps (planning).

Notably, a patient’s medical record should contain all SOAP reports. 

The Importance of SOAP reports

SOAP enables psychologists and psychiatrists to communicate efficiently, providing patients with better care. SOAP reports increase psychiatrists’ accuracy and concision. They also support your end goal of delivering effective treatment care for your clients. 

How to Use SOAP Reports

Let’s examine the SOAP report contents so you can record your clients’ sessions properly.

(S) Subjective

This is where you record the patient’s presenting issues and any other relevant information. You should include the client’s progress from the last visit. It also gives an elaborate account of the client’s symptoms.

However, don’t make statements unless you have facts to support them. Take only relevant information and opinions from loved ones or clients that indicate motivation, willingness, and awareness to participate into consideration.

(O) Objective 

This part details client information like appearance, diagnosis, body posture, mood, and impact when discussing specific issues. Also, you can include the client’s strengths, responses, and ability to participate in therapy sittings.

However, it would be best to avoid personal judgments, assumptive statements, and value-laden language.

(A) Assessment

In this section, you should interpret the client’s information using your knowledge. You should include observation in line with the therapeutic model by applying clinical knowledge. Also, you should include whether the client is experiencing anxiety or family-related stressors.

Nonetheless, you should avoid reiterating your previous statement. 

(P) Planning (Client Plans)

Summarize how you intend to progress with the treatment given what’s happened so far. Plan your next session steps by aligning overall treatment plans and assessment without reiterating. But, avoid establishing unrealistic goals before the client session or restating overall treatment procedures instead of future session goals.

Psychonline software will save you time and help you document better. Want to know more? Feel free to enroll for a schedule a live demo or free trial.