Soap note templates are a kind of progress reports that are prepared in a chart format to record the conversations between a medical practitioner and his/her patients. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. It is a method of documentation of the patient’s progress with the therapy.
Soap Note Template- What it should contain
Each section of the SOAP note should contain the following details:
Clinically admissible details that the patients tell the practitioner (except how they respond to today’s treatment). This might include changes in the condition, treatment response, etc.
Clinically admissible observation that the practitioner gains by his/her clinical examination on that patient visit. Under objective details, the practitioner must record any valuable change that they palpate or observe during that visit. This might include changes in general appearance, body language, affect, demeanor and responsiveness.
The practitioner’s observation or assessment of how the patient is progressing. This might include reflection on the patients improving/worsening condition or static condition.
Today’s treatment, response and plans for follow up and future care. This might include details about the immediate response to the treatment, patients instructions, future treatment plans, etc.
Free Printable SOAP Notes
All the SOAP templates available online have at least four sections that is for the subjective, objective, assessment and plan details. Some templates provide additional sections for other details and in-depth details too.
Some of the templates available online are:
- Physical therapy soap note
- Psychiatry soap note
- Counseling soap note
- Cardiology soap note
- Clinical progress note
Physical Therapy SOAP Template
This note is specially designed for physical therapy sessions. It has space to fill in the initial details of the patient’s physical conditions with close-ended options to tick on. The subjective and assessment section of the note is open-ended to record the specific point of views of the patient and practitioner respectively, while the objective and plan sections have logical close ended options to choose from.
Psychiatry SOAP Note
This SOAP note is used for psychiatric sessions and has readymade questions for the patient’s state of mind which makes the later evaluation of different sections i.e. subjective, objective, assessment and plan easier. The note has added options for any other services that the patient is availing.
This is a specially programmed report for counseling sessions with closed-ended options and other details of the patient to fill in. The ‘observed/reported changes in condition’ section corresponds to the subjective section of the note while the ‘stressors/extraordinary events’ section corresponds to assessment section of the note.
Cardiology Note Template
This is a specially programmed for cardiology sessions with fields like a chief complaint, history of present illness in subjective section and clinical exam- extraoral, intraoral and radiology which adds to the value of the details recorded and makes the information look properly classified and comprehensible.
This is a clinical progress note with two parts to fill in, patient assessment and soap note. The patient assessment division makes it easier to figure out the patient’s response and the practitioner’s assessment and hence makes the soap note seem more sensible.