How SOAP notes contribute to patient collaboration

How to write better SOAP notes in collaboration with your patients Organizations like OpenNotes¹ based in Boston, MA, have spent decades researching the topic of accessible notes and collaborative care in Behavioral Health practices, revealing that among many things, the notes taken by behavioral health professionals have a large impact on the quality of care patients² receive under their care. For professionals working in mental healthcare, it is important to remember the most essential audience member in each care team - the patient. We can prioritize patient perspectives by using a framework that is both intuitive and concise, which will create opportunities for the patient to not only easily understand and build on these notes, but to also collect their own thoughts and contribute in a meaningful way to your interactions in session, and their progress outside of it. As the body of research supporting patient collaboration continues to advance, there is a growing gap with PMS and EMR tools not supporting recommended collaborative care practices to optimize patient care. Collaborative documentation³ offers many routes for improving quality of care and consistently generates positive outcomes with less administration. What is a SOAP note? In case you’re new to the latest in clinical documentation, let’s start with what exactly a SOAP note is. First, it doesn’t have much to do with showers, cleansing agents, or loofahs. It’s actually an acronym for a note-taking standard which stands for Subjective, Objective, Assessment, and Plan. This widely accepted standard notation format is used across health professions to record details of patient treatment sessions. Since all SOAP notes follow the same structure, all patient information is clearly laid out and others will know how to consume the information when reviewing the details. Why use SOAP notes? With the complex nature of medical disciplines, it can be challenging for different professionals to collaborate over a shared patient. This can lead to reductive and prolonged treatment when healthcare professionals cannot collaborate effectively with their patients and each other. SOAP notes allow practitioners in the health and wellness industries to document their findings in a simple and predictable manner, allowing others to consume the information quickly and efficiently. In addition, SOAP notes contain essential pieces of information that help inform the practitioner about the ongoing health status of their client. How to write a SOAP note There is a specific structure attached to the SOAP note format which keeps notes clean and organized, allowing professionals to assess, diagnose, and treat patients using the right information. This format is also easily recognizable by healthcare providers in other specialties making it easy to coordinate care for your clients with other practitioners. Keep reading to learn about how patient collaboration fits into the equation! What to include in a collaborative SOAP note? The format of a SOAP note is the same across all fields, but the content will depend on your speciality, who your client is, and what you’re working on during your sessions together. When done well, all the details necessary for the client, their care team, and the payor can all be included efficiently. Here’s a breakdown of the structure of a SOAP note, along with suggestions on what should (and shouldn’t) be included to follow current best practices. Subjective This section is for personal reporting from interactions with your patient. It can include their observable and reported mood, their reported symptoms, and the actions they have taken since your last meeting to implement your homework or recommendations, along with any questions they might have. Start with the client’s history. This can include: Medical and mental health history Medications Day-to-day routines Client reported information Should not include: Statements without supporting evidence Unsourced opinions It is important to remember that all subjective information presented must be sourced, whether it's yourself, your client, or any third party, as we do not want to present this information as fact. Objective Unlike the previous section, this section is preserved for information that can be measured and quantified. This might include specific interventions used in the session or measurable outcomes, like test scores and milestones achieved. Keep things to-the-point and brief. This can include: Client mental status Physical and psychological observations Relevant reports Client behavior Interventions used Should not include: Personal opinions Statements without supporting evidence Assumptions When discussing specific clinical interventions, recording why you chose an intervention and how it relates to the overall treatment plan should be made clear. Assessment This section describes your interpretation of the session and your clients progress towards their goal(s). Keep things brief and to-the-point. This can include: Your analysis of information in Subjective and Objective sections Clinical and professional knowledge to interpret your client’s problems DSM criteria / Therapeutic Model to identify the issues and treatments Risk assessments that were used (e.g. CSSRS) Should not include: Information previously documented Information you’d rather the patient not read Review your clients progress or regression over time, and assess factors that contributed to it. Again, remember that brevity is your friend. In the spirit of collaboration, please make sure to share your assessment with your client. Plan This section should focus on next steps following this session, leading into the period before your next section. Any adjustments to the treatment plan, additional homework, and overall changes. It is important to make sure important details are highlighted clearly. This can include: Progress or regression Next steps for upcoming sessions How you’ll implement treatment and next steps Any physical, mental, and nutritional elements that could have an effect Safety plan Any prescribed SMART goals that were created Should not include: Information previously documented Unmeasurable goals Unrealistic goals This section is for tracking progress or regression and making necessary adjustments to the existing plan to help your patient meet their goals. But please do not rewrite an entire treatment plan, and instead make the necessary modifications to keep documentation accurate and brief. How to incorporate collaboration into session notes As our knowledge of best practices continues to evolve in health care, more information continues to support that idea of patient stewardship in their own health journeys. Here are some elements every professional can consider when delivering care to their patients, or choosing digital tools to support their practice. Consider having patients write pre-session journals. Getting them to reflect prior to starting the session can often lead to more focused conversations while minimizing time spent catching up. Encourage patients to reflect on how the session has gone and give them an opportunity towards the end of each session to record those details and share them with you. The details on how they perceived aspects of the session can provide valuable insights you can include in the formal session notes. With the details captured above, consider filling out the session note together. Patients will often surprise you with their ability to summarize the session, and this will create an opportunity for you to see what was important from their perspective. This can be a powerful tool to ensure you’re both on the same page. Provide a questionnaire either at the end of the session or in a follow-up email. Focus on getting feedback on how effective your session was from the perspective of each patient. Feedback can offer insight into the quality of the therapeutic alliance and ensure the patient is satisfied with their care. With the right tools and technology, having access to quick summaries of patient homework between sessions in a non-intrusive way that respects your administrative capacity is a great way to keep up with how each patient is doing, and makes subsequent sessions more efficient with less catch-up. This can come in the form of visibility into whether homework was completed or seeing a snapshot of how patients scored on certain validated questionnaires directly through your EMR. With the right investment in technologies, these collaborative elements can be included directly into your patient interactions, allowing you to reap the benefits of a strong collaborative care model with zero additional administration! How to use SOAP notes in EHRs Most practice management systems support SOAP notes in some capacity along with other note taking templates built right into the platform. Premium digital tools will not only embed your notes with the patient profile so that it can be viewed together, but will also allow the patient to include their perspectives from the session into your session notes. For those of you wondering, all payor requirements can be included in the SOAP note. The golden thread that ties the diagnosis, goals, objectives, and treatments should ultimately fit into the patient record. Combined with documentation on risk assessments performed and the integration of outcome measures to determine whether goals are being reached, you’re one step closer to keeping the entire care team, your payors, and your clients happy. If you've been considering switching to a fully integrated HIPAA (US) or PIPEDA (CAN) compliant practice management software, Speakbox Care gives you everything you need to streamline your entire practice. You can pull SOAP note templates from our template library, use our documents feature to store additional information, add supplementary details to each patient profile, and most importantly - gain critical insight into your patients before, during, and after sessions, along with everything in between. References: Open Notes (https://www.opennotes.org/mental-health-professionals/) (2019) Using Clinical Documentation Improvement to Improve Patient Care (https://www.longwoods.com/content/25772/using-clinical-documentation-improvement-to-improve-patient-care) (2017) A Qualitative Analysis of How Online Access to Mental Health Notes Is Changing Clinician Perceptions of Power and the Therapeutic Relationship, Lauren M Denneson, Risa Cromer, et al. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5489707/)

How SOAP notes contribute to patient collaboration

Want to know more about Speakbox?