Soap note
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This document outlines the components of a SOAP note, which is used by healthcare professionals to document patient encounters. A SOAP note includes sections for Statements, Observations, Assessment, and Plan. The Statements section describes what was discussed during the visit or session. Observations provide details about the patient's appearance, mood, and affect. The Assessment gives the healthcare worker's analysis and impressions. Finally, the Plan outlines the goals and next steps for treatment between visits.
Soap note
- 1. SOAP Note: S -- Statements: What was said; describe the content of the interview or the session (2-3 sentences) O -- Observations: The worker's observations about the client's affect, mood appearance, etc. A -- Assessment: Your impression; what do you make of the client's behavior? What is going on with the client? P -- Plan: What is the plan? How will you and the client proceed? What should be done by you or the client between now and the next visit?