Progress Notes Soap: Fill & Download for Free

SOAP is one of several formats for organizing progress notes on charting.S - SubjectiveO - ObjectiveA - AssessmentP - PlanYou'll also find SOAPIE, SOAPIER, etc.

I don’t normally write “non-serious” medical answers, but some of these are - so if I don’t get many upvotes, I’ll probably decide to abandon humorous responses. I don’t necessarily consider these “Neat”, but nonetheless, they are characteristic of (someone’s) pathology. For what it’s worth -A “Checkup from the neck up” - psychiatric consultChronic Recurrent Abdominal Pain - a term used by frustrated doctors who can’t find a reason for the patient’s abdominal symptoms (I’ve learned that our inability to find a cause for someone’s symptoms doesn’t make them any less real)Dump - A patient with multiple medical problems and no insurance transferred to the charity hospitalDumpling - pediatric version of aboveEuboxia - all lab values are within the normal range (fall inside the box)A follower of Bacchus - Used by residents when presenting a patient (at the bedside) when they are uncomfortable saying that the patient is an alcoholic. (Comment: Even doctors may help patients maintain their denial)SOAP note - a progress note containing - Subjective (patient’s stated symptoms) - Objective (physical signs, lab, x-rays, etc.) - Assessment - what is going on with the patient - their diagnosis or other significant characteristics of their condition - Plan - What to do next in evaluation or treatment.Trichotillomania (the urge to pull out one’s hair due to a genetic disease called Trichomalacia) produces bald spots due to that compulsive urge. Trichomalacia is also the resulting condition (absence of hair -bald spot)Q - So, what’s the difference between a hematologist and a urologist?A - A hematologist pricks your finger…..Q - So what’s the difference between an orthopedic surgeon and a carpenterA - A carpenter usually knows the name of more than one antibiotic

I think that doing a good treatment plan makes progress notes easier to write as well as keeping the therapeutic enterprise focussed. Abbreviations helped: LTG (Long Term Goal), d/o (disorder), etoh (alcohol) and, so on and so forth. Some people did SOAP notes (Subjective, Objective, Assessment and Plan).Meaningful progress notes meant I could review them prior to a session and have a good idea of where the client and I had been, where we were and, the options and directions we had for the upcoming work.The real strategy for keeping up with notes was to never leave work until they were done. If it meant having a working lunch or staying late, so be it. Once the camel’s nose was in the tent, you never caught up.For a while my agency experimented with dictating progress notes, evals and treatment summaries. Heaven on earth until the bill came in.The volume of paperwork for substance abuse was, frankly, depressing. You didn’t keep up. You just kept adding to the pile and hoped for a snow day.Once a year the state would send out a team of examiners to make sure there was no fraud (billing for phantom sessions), the notes reflected with clarity and clinical astuteness the work being done and, lived up to the level of quality demanded by the State of Maine regulations governing mental health and substance abuse agencies. Charts had to be reviewed by the clinician as well as be peer reviewed by co-workers. Nights and weekends for this one.I won’t even mention JAHCO, the Joint Commission on health provider’s accreditation. Or discuss managed care paperwork requirements.If need be, I would write a separate note for my own record, one that would reflect the nuances of what really transpired in those 50 minutes. What unfolds in therapy does not always lend itself to the somewhat inflexible formatting demanded by federal, state and agency policies. We have to "render unto Caesar the things that are Caesar's.”