8+ Sample Soap Assessment

What is a SOAP Assessment?

A SOAP assessment is a comprehensive method used by many professionals in various industries such as education, mental health, occupational therapy, physical therapy, social work, nursing, and many others to analyze and document every individual encounter to preserve the event for future reference, as well as in accounting and legal purposes. It includes the SOAP note, an intake progress note and a documentation plan for outpatients, medical historical records, physical examination, assessments of various diagnoses, and investigative treatment plans. This is documented in the format of subjective, objective, assessment, and plan which is the pattern integrated for daily inpatient encounters such as comprehensive physical exams and other medical evaluations.

SOAP assessments enable medical practitioners to record a synthesis of subjective and objective evidence to give an in-depth diagnosis and assess the patient’s progress through a standardized analysis of the issue, potential interaction, and status changes. Additionally, it provides accurate information regarding the medical treatment plan, especially on how the patient is responding to the treatment, and the progress or improvements made by the patient. Thus, a SOAP assessment contains medical diagnoses, patient progress, and medication or treatment plan changes.

Types of SOAP Assessments

There are a wide variety of SOAP assessments used by many educators, doctors, nurses, physical therapists, and other medical professionals in different clinical fields. Here are some common types of SOAP assessments.

Student Performance Assessment: Educators, teachers, and other academic professionals conduct SOAP assessments and use SOAP notes and student assessment reports during student performance assessment to evaluate and compare the ability of students to perform in each area of the subjective, objective, assessment, and plan or SOAP note during their practical experiences within an academic year. The students are required to submit two SOAP notes. Then, each SOAP note will be assessed by a full-time faculty member in their department. Using a rubric with a scale of 1 to 5, the students are rated based on their skills and experience to perform in each area of the SOAP note and their SOAP notes will be assessed to see the students who performed well regardless of the semester they took. Mental Health Counseling Assessment: Psychologists, therapists, and other mental health counselors use the most common and reliable mental health assessment tools to support and enhance the well-being of their clients. They use SOAP assessment along with other mental health assessment tools such as Minnesota Multiphasic Personality Inventory (MMPI-2), Beck Anxiety Inventory, Beck Depression Inventory, and other holistic mental health assessments. Also, there are other psychological tests and assessments given such as the Brief Dissociative Experiences Scale, Amsterdam Misophonia Scale, Intolerance of Uncertainty Scale Short Form, and other worksheets for therapeutic processes or sessions. There are some questions mental health counselors and psychiatrists need to use in the assessment of your client: Were there times when the patient where so active or hyper that he or she couldn’t slow down? Were there any periods when the patient was very sad or depressed? Then, tie up the mental health questions in specific timeframes. You may also use some worksheets available online to assist you in assessing your patient’s mental health. For example, the Cognitive Fusion to Defusion worksheet on Quenza is designed to help your patients take a moment when they are overwhelmed because of their self-critical thoughts. Or during the assessment, encourage your patients to apply the S.O.B.E.R Stress Interruption Technique, an exercise with a digital worksheet from Quenza to help patients during their stressful times as they can start by listening to an eight-minute audio meditation that helps them do the S.O.B.E.R. steps (Stop, Observe, Breathe, Expand awareness, and Respond with awareness). Physical Therapy Assessment: Also known as PT initial evaluation, physical therapists spend time with their patients to learn and understand more about their conditions, their previous function levels, and how their conditions are affecting their daily lives. These assessments will help physical therapists to take accurate measurements of the impairments that may be causing their problems and develop a treatment plan for the patients. A physical therapy assessment should include a comprehensive medical case summary and physical examination of the patient and guides physical therapists to evaluate their patients based on their personal levels of strength, mobility, posture, skin integrity, flexibility, balance, coordination, range of motion, and other neurological factors. Social Work Assessment: This assessment is carried out by a social worker to offer a therapeutic response to fulfilling needs or resolving issues. Social workers use various assessment tools such as formative assessment, summative assessment, situational analysis, needs analysis, and impact assessment. A social worker schedule interviews, review documents and interview the clients for this assessment.

Basic Elements of SOAP Assessment Note

Assessments using SOAP notes are essential to help medical practitioners to create medical reports and effective treatment plans for their patients, as well as a healthcare operational plan. In this section, learn about the basic elements and structure of a SOAP assessment note.

S for Subjective or Symptoms This category tells the history and interval history of the patient’s condition. Describe the complaints of the patient in some detail in the SOAP notes of each and every office visit. It is recommended to write down the patient’s own words. It is usually not sufficient to use one-word entries or short phrases in routine such as “better”, “same”, “worse”, “headache”, and “back pain”. In follow-up notes, “S” is a reiteration of the major complaints revealed during the patient’s initial evaluation. The complaints or problems should reflect change over time. Record the patient’s responses to the previous treatment, resumption of daily or occupational activities, intervening injuries, and exacerbations. Explain the significant improvement in the patient’s activities and physical capacities in the interim since the last treatment. Add in this section clear and detailed explanations for any hiatus in treatment and the patient’s compliance with recommended home care. O for Objective or Observations: This part includes inspection (e.g., “patient still walks with antalgic gait”) and more formalized and in-depth reevaluations such as provocative tests, ranges of motion, specialized tests (fixations, tongue, pulse, BP, labs). The scope of the reevaluation at each office visit depends on the information recorded in “S” together with the original positive clinical findings and the changes in “O” at previous office visits. Typically, only the critical indicators should be repeated. Make sure that the medical findings are qualified and quantified so that you are able to examine progress/response to care over time. Medical treatment indicators should always be specified in order to document the necessity of the treatment given and described in the “Plan” section of the note, for example, abnormal lab values, motion palpation findings, and stagnation of blood. A for Assessment: Based on the “S” and “O” elements of the SOAP assessment note, this section is the diagnostic impression or working diagnosis. On follow-up visits, the “A” should demonstrate significant changes in “S” and “O” as a response to time, treatment, and other interim events (e.g., “Cervical strain, resolving” or “exacerbation of left sacroiliac pain”). It should be updated continually to show accuracy in the representation of the patient’s current health condition. Other contents of this section may have the following where appropriate: laboratory or procedure results, outside consultation reports, patient risk factors or other health concerns, and a detailed review of medications. P for Plan or Procedure: State in this part the initial treatment plan of the patient’s first visit. A complete treatment plan is composed of medical treatment frequency, duration, procedures, anticipated outcomes, and major goals of treatment. An initial treatment plan may be for an initial trial of treatment over a short interval with a re-assessment and more treatment planning at a later time. On each follow-up visit, you need to identify the modalities and procedures performed that day, continuation, or changes in the overall medical treatment plan. Also, describe what the patient is to do between office visits, what the anticipated course of medical treatment is, what additional tests might be ordered, and the disposition of the case if it is a discharge or a referral. Add in this section any comments with respect to the patient’s compliance.

How to Document a SOAP Assessment

After knowing the basic elements of a SOAP assessment note, you need to follow the basic SOAP framework to help you structure your documentation properly in a consistent manner. Keep it clear and organized while writing the essential details of the assessment.

Step 1. Write the Subjective Section

When you write this section, indicate how the patient is currently feeling and how they have been since the last medical review in their own words. Ask your patient some questions: How are you today? How have you been since the last office visit? Have you currently got any difficult symptoms? Explore each of the multiple symptoms mentioned by the patient and describe them in their own words. Write down the patient’s responses accurately and use quotation marks to directly quote what the patient has stated.

Step 2. Record the Objective Observations

Include in the objective section your objective observations or the things you can see, measure, hear, feel, or smell such as the appearance, clinical examination findings, fluid balance, vital signs, and other medical investigation results. Describe the appearance of the patient, and record the patient’s vital signs such as blood pressure, pulse rate, respiratory rate, and temperature. Include an assessment of the patient’s fluid intake and output such as oral fluids, intravenous fluids, nasogastric fluids or feed, urine output, vomiting, and drain output.

Step 3. Detail the Assessment

Document your thoughts on the clinical diagnosis and the salient issues based on the gathered information in the previous sections. Summarise the salient points (e.g., “Increasing shortness of breath”, “Raised white cell count (15) and CRP (80)”, “Chest X-ray revealed increased opacity in the right lower zone, consistent with consolidation”, etc.) Write down your impression of the diagnosis. If it is an already-known diagnosis, include comments on whether the patient is clinically improving or deteriorating.

Step 4. Outline the Plan

Develop a treatment plan on how you will address or further investigate any problems raised during the clinical review. Incorporate in your plan some necessary items such as more medical investigations like laboratory tests and imaging, medical treatments such as nutrition, medications, intravenous fluids, and oxygen, referrals to specific specialties, time and date of review, frequency of observations and monitoring of fluid balance, and planned discharge date.

FAQs

What should be included in the SOAP note assessment?

The SOAP note assessment should include your major observations from the assessment which are the things you can measure like the vital signs, fluid balance, clinical examination findings, and investigation results. Record the patient’s vital signs such as blood pressure, pulse rate, respiratory rate, SpO2 (supplement oxygen), and body temperature. When assessing the patient’s fluid intake, you must include the output of the patient such as the nasogastric fluids, intravenous fluids, drain output/stoma output, oral fluids, intravenous fluids, urine output, and vomiting. Some medical investigation result examples that you may add are recent lab results like blood tests and imaging results like chest X-rays. 

What are the basic elements of a SOAP note?

The basic elements of a SOAP note are subjective, objective, assessment, and plan.

What is the importance of writing SOAP notes?

Writing SOAP notes is important for academic professionals and medical specialists to document what they accomplished and observed to help them track the results, scores, or goals in the assessment.

It is integral to document and explain the core points of SOAP assessment work in various fields and industries such as education, mental health, physical therapy, and other medical fields. Take note of the different SOAP assessments, the basic elements of a SOAP assessment note, and the basic steps to document a SOAP assessment for your patients. Thus, here are some of our sample downloadable and printable SOAP assessment document templates available in PDF format. Browse and use the sample SOAP assessments and other assessment forms available on Sample.net such as a client biophysical assessment and a project assessment plan.