This statement is vague, and it is unnecessary to write “was able to.” This statement gives specific information regarding the client’s behavior under specific circumstances without being judgmental.Īvoid: “The client was able to write her name.” Use instead: “The client did not verbalize his name after being prompted twice by the clinician, ‘Tell me your name.’” This statement is judgmental and makes an assumption about the client’s ability without specific evidence to substantiate it. This statement quickly draws a conclusion that might be helpful for a future practitioner.Īvoid biased overly positive or negative phrasing.Īvoid: “The client could not even say his own name.”
Use instead: “The client shows greater success with activates involving physical cueing.” This statement is overly wordy and could be simplified to state the main idea in a quicker and more precise manner. This statement specifically describes the actions of the client and maintains a formal voice.Īvoid: “Careful consideration and thought have lead this clinician to conclude that the client responds very positively to physical cues.” Use instead: “The client smiled and laughed during the group therapy session.” “Had a blast” is informal and not descriptive. You should take personal notes for yourself that you can use to help you write SOAP notes.Īvoid: Waiting too long after your session with a client or a patient has ended.Īvoid: “The client had a blast during the group therapy session.” Tips for Effective SOAP Notesįind the appropriate time to write SOAP notes.Īvoid: Writing SOAP Notes while you are in the session with a patient or client. The resource discusses the audience and purpose of SOAP notes, suggested content for each section, and examples of appropriate and inappropriate language. This resource provides information on SOAP Notes, which are a clinical documentation format used in a range of healthcare fields.
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