Free SOAP note templates and examples for practitioners
Why it’s important to use a SOAP Note template
Looking for a fast and easy way to keep track of your treatment notes? You need a SOAP Note template. A template is a file that’s designed to be replicated, so all your documents look the same. Using a template saves A LOT of time. You don’t have to create your notes from scratch. Plus, using a template will make your notes consistent and look professional.
Having that consistency helps you stay organized. You can scan notes quickly, and easily find what you’re looking for. If you have multiple therapists in your practice, you need to have a system for recording and sharing client information. SOAP Notes are the best way to do that. If everyone uses the same template, it makes life easier.
There may be times when you need to share information with other healthcare providers or insurance companies. The documentation you provide must look professional. A SOAP Note template provides a framework for sharing information in a clean, concise and professional way.
Looking for a fast and easy way to keep track of your treatment notes? You need a SOAP Note template. A template is a file that’s designed to be replicated, so all your documents look the same. Using a template saves A LOT of time. You don’t have to create your notes from scratch. Plus, using a template will make your notes consistent and look professional. Having that consistency helps you stay organized. You can scan notes quickly, and easily find what you’re looking for. If you have multiple therapists in your practice, you need to have a system for recording and sharing client information. SOAP Notes are the best way to do that. If everyone uses the same template, it makes life easier. There may be times when you need to share information with other healthcare providers or insurance companies. The documentation you provide must look professional. A SOAP Note template provides a framework for sharing information in a clean, concise and professional way.
Want A Free SOAP Notes Template?
We partnered with the AMTA to create a printable SOAP note template for massage therapists, physical therapists, occupational therapists, multidisciplinary clinics, and more!
What should you include in a SOAP notes template?
A SOAP note should include treatment plans and benchmarks like the reason for the client’s visit, your observations, treatment details, and a game plan for subsequent sessions. You might also include a couple of personal notes where appropriate. Check out some how to write a SOAP note examples below.
Subjective
This is where you record what the client tells you, including: health history, lifestyle, symptoms, etc.
Example: Low back pain after long hours of sitting at her desk job. Sedentary lifestyle and no previous injuries.
Objective
This is where you record what you see and feel, including: p alpation, scars, bruising, postural distortions, ROM, etc.
Example: She has a hard time standing up straight. Tension in QL. Weakness in glutes and hamstrings.
Assessment
This is where you describe what the treatment consisted of and the client's progress. Record things like orthopedic tests, treatment methods and outcomes.
Example: Deep tissue massage on the low back, hip flexors and glutes. She was able to stand up straight after treatment and reported no pain.
Plan
This is where you detail plans for the next session and recommendations for self-care.
Example: Focus on hips and lower back next week. Recommended taking a walk on her lunch break to prevent things from stiffening up during the work day.
In addition to treatment notes, consider adding a section for personal notes. Results and relationships improve when you have a real connection with your clients. It’s a good idea to write down a couple things to jog your memory about who your client is. It could be a small detail about their life, family or work. Use it as a conversation starter next time you see them.
Is client paperwork adding up? Are SOAP notes taking too long? Do you wish you could be more precise with your client treatment plans? It sounds like customizable customizable SOAP notes softwareis right for you!
ClinicSense provides 3 types of SOAP notes + you can create your own with the treatment note builder!
New Fully customizable SOAP notes
Now you can have a SOAP note for all scenarios - whether that’s a quick update or a fully detailed note and treatment plan.
Choose from 15 different question types including short answer, multiple choice, pain scale, and more!
+ 3 Different SOAP notes styles depending on what you need.
1. Point & Click SOAP Note Not into writing? Prefer pictures to words? Use this SOAP Note to quickly record your treatment notes with minimum fuss.
2. SOAP Note with “short codes” Prefer written notes, but don’t want to take the time to write them all out? Use this SOAP Note to create written notes fast.
3. General SOAP Note Prefer a blank slate? Use this SOAP Note to take a few quick notes or record extensive details.
ClinicSense provides 3 types of SOAP notes+ you can create your own with the treatment note builder!
No two businesses are alike, and every practitioner has their own preferences. That’s why ClinicSense created 3 different types of SOAP Notes. No matter what your note taking style is, there’s a SOAP Note that works for you. You can even create your own template, if you want something more custom.
1. Point & Click SOAP Note - Not into writing? Prefer pictures to words? Use this SOAP Note to quickly record your treatment notes with minimum fuss.
2. SOAP Note with “short codes” - Prefer written notes, but don’t want to take the time to write them all out? Use this SOAP Note to create written notes fast.
3. General SOAP Note - Prefer a blank slate? Use this SOAP Note to take a few quick notes or record extensive details.
4. Create your own SOAP Note Template - Your business is unique. That’s why ClinicSense gives you the option to customize your SOAP note template to fit your exact needs. Use the treatment note builder to decide what’s included in your SOAP note and what’s not.
Your SOAP Notes and forms are designed specifically for the type of service(s) you provide. They prompt the right questions at the right time, no matter who your client is. Whether you’re in a multidisciplinary setting or a solo practice, you can tailor your SOAP Notes to your business.
For example, if you offer both prenatal massage and neuromuscular therapy, you can use different templates for each service since you will record different information for each service type.
These built in features will streamline your information gathering process.
Use different templates for different services
Choose from prebuilt questions. Use only the ones you want, when they are relevant
Create your own questions and line of questioning
Automatically eliminate questions that aren’t applicable, based on client responses. Example: If a client answers “no” to being pregnant, they won’t be asked to answer questions about their pregnancy.
Automatically prompt specific questions when you need more details. Example: If a client answers “yes” to having pain, that will prompt more questions about pain level, sensation and location.
Plus, all these notes are securely stored online, so no need for paper files.
Not ready for online SOAP Notes? Download our FREE SOAP Note template.
If you’re not ready for clinic management software yet, we can still help. We partnered with the American Massage Therapy Association to create this SOAP Note template. You can download it now, and start using it right away.
Keep in mind, paper SOAP notes have their limitations.
They take time to organize.
They take up physical space.
You can’t automate them.
You have to keep paper and ink in stock.
Writing takes more time than a point and click.
You only have access to them when at the office.
If you're just getting started, those limitations may not pose a problem. However, as your business grows, that paper will start to pile up. Eventually, you’ll have more demands on your time and will need to simplify your systems. If you don’t, you’ll be stuck spending a lot of extra time organizing files and doing admin work. Those are minutes you don’t get paid for.
We partnered with the AMTA to create a printable SOAP note template for massage therapists, physical therapists, occupational therapists, multidisciplinary clinics, and more!
Ready to say goodbye to paperwork?
Join the 7,500 health and wellness practitioners who use ClinicSense to manage their business!
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