Posted on January 7, 2021
Do you record SOAP Notes for each of your clients’ treatment sessions? SOAP Notes are a way for massage therapists and other healthcare providers to map where a client has been and where they are going. The unique SOAP format (Subjective, Objective, Assessment, and Plan) of these reports helps you keep track of your client’s condition and progress through each treatment session.
SOAP Notes can be time-consuming to complete. But don’t underestimate the importance of this record-keeping method. Well-written, detailed SOAP Notes enable you and your staff to quickly memorialize and communicate essential information about a person’s current health status and their ongoing treatment plan.
When recorded properly and consistently, these notes can become your guide to providing each of your clients with personalized, effective treatment. SOAP Notes can also be used to support medical billing or legal claims by providing evidence of the services you have provided to a client. Plus, because the SOAP format is recognized across medical disciplines, SOAP Notes are an important tool for communicating with other members of your client’s healthcare team.
How can you create well-written SOAP Notes that help keep everyone on the same page?
To get started, follow these steps:
- Use a standard format for all of your notes. SOAP notes should be easy to recognize and navigate. Using a standard template for each client’s treatment sessions will make it easier for you and others to quickly find information in your notes.
- Develop a system for maintaining and filing your notes. You don’t want to mix up your client’s records or have to dig through stacks of papers on your desk when you need to investigate something about their treatment. So, create a filing system and diligently maintain it. Create a separate folder for each client and store them alphabetically.
When you put new SOAP Notes in a client’s folder, place them in order by date. Use reverse chronological order so that you can put the most recent notes on top--this makes the task of filing faster and easier.
- Complete a new SOAP Note for every treatment session. SOAP Notes aren’t effective if they aren’t complete. While capturing all the necessary details during your client’s session may be a challenge if you are using manual note-taking methods, it’s important to complete them. Make sure you schedule enough time between clients to write your SOAP note. And if you’re running behind schedule, don’t let too much time pass between a treatment session and the completion of your notes - you may forget important details.
- Prepare your notes with clarity and professionalism in mind. Whenever you write your SOAP notes, remember that it is a device that may be viewed by other people. Maintain a professional tone and write legibly. Don’t use personal shorthand or add extraneous commentary to your SOAP notes. Do include enough detail so that someone who is not familiar with your client’s treatment history can be quickly brought up to speed.
Speed up your note taking and streamline your filing by going digital with help from ClinicSense
Taking handwritten notes using a printed form can get the job done. But, if manually recording and filing your SOAP notes seems like too much of a drag on your time, there is an alternative.
A lot has changed since the concept of SOAP notes was first developed. Today, digital SOAP notes put a digitized template into the palm of your hand.
When you use a digital SOAP notes app like the one from ClinicSense, much of the information you would normally record using handwriting can be entered by pointing and clicking. Pre-set questions prompt you to add important details and generate neat legible reports. Shortcodes allow you to enter common words and phrases fast. Plus, client data is saved and stored digitally so you don’t end up with piles of paper on your desk.
Your client’s SOAP notes create a personalized treatment map, showing everyone on their healthcare team where they have been and where they are going. They ensure continuity of care and enhance communication between you and your client. Don’t miss the opportunity to create well-developed SOAP notes because of the pressures of time. Let technology lend you a hand and use digital SOAP notes to keep you and your clients on track.