In every mental health treatment facility across the country, counselors are required to accurately document what has transpired during the therapeutic hour. Over the course of the past few years, the importance of documentation has gained more emphasis as third-party payers have changed the use of documentation “from something that should be done well to something that must be done well” (Kettenbach, 1995, p. iii). In this era of accountability, counselors are expected to be both systematic in providing client services (Norris, 1995) and able to produce clear and comprehensive documentation of those clinical services rendered (Scalise, 2000). However, in my experience (i.e., first author), both as director of a mental health clinic and as one who audits client records, few counselors are able to write clear or concise clinical case notes, and most complain of feeling frustrated when trying to distinguish what is and is not important enough to be incorporated in these notes. Well-written case notes provide accountability, corroborate the delivery of appropriate services, support clinical decisions (Mitchell, 1991; Scalise, 2000), and, like any other skill, require practice to master. This article discusses how to accurately document rendered services and how to support clinical treatment decisions.
When counselors begin their work with the client, they need to ask themselves, What are the mental health needs of this client and how can they best be met? To answer this question, the counselor needs an organized method of planning, giving, evaluating, and recording rendered client services. A viable method of record keeping is SOAP noting (Griffith & Ignatavicius, 1986; Kettenbach, 1995). SOAP is an acronym for subjective (S), objective (O), assessment (A), and plan (P), with each initial letter representing one of the sections of the client case notes.
SOAP notes are part of the problem-oriented medical records (POMR) approach most commonly used by physicians and other health care professionals. Developed by Weed (1964), SOAP notes are intended to improve the quality and continuity of client services by enhancing communication among the health care professionals (Kettenbach, 1995) and by assisting them in better recalling the details of each client’s case (Ryback, 1974;Weed, 1971). This model enables counselors to identify, prioritize, and track client problems so that they can be attended to in a timely and systematic manner. But more important, it provides an ongoing assessment of both the client’s progress and the treatment interventions. Although there are alternative case note models, such as data, assessment, and plan (DAP), individual educational programs (IEP), functional outcomes reporting (FOR), and narrative notes, all are variations of the original SOAP note format (Kettenbach, 1995).
To understand the nature of SOAP notes, it is essential to comprehend where and how they are used within the POMR format. POMRs consist of four components: database, problem list, initial plans, and SOAP notes (Weed, 1964). In many mental health facilities, the components of the POMR are respectively referred to as clinical assessment, problem list, treatment plan, and progress notes (Shaw, 1997; Siegal & Fischer, 1981). The first component, the clinical assessment, contains information gathered during the intake interview(s). This generally includes the reason the client is seeking treatment; secondary complaints; the client’s personal, family, and social histories; psychological test results, if any; and diagnosis and recommendations for treatment (Piazza & Baruth, 1990). According to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, 2000), with special populations, as in the case of a child, the clinical assessment contains a developmental history; for individuals who present with a history of substance abuse, a drug and alcohol evaluation is included.
From the clinical assessments, a problem list (second component) is generated, which includes an index of all the problems, active or inactive, derived from the client’s history. Problems are defined as either major areas of concern for the client that are not within the usual parameters when compared with others from the client’s same age group or as areas of client concern that can be changed through therapeutic intervention (JCAHO, 2000). As problems are identified, they are numbered, dated, and entered on the list, and this problem list is attached to the inside cover of the client’s file, for easy reference. As the identified problems are resolved, they are dated and made “inactive.”
The third component of the POMR is the treatment plan, which is a statement of the possible therapeutic strategies and interventions to be used in dealing with each noted problem. Treatment plans are stated as goals and objectives and are written in behavioral terms in order to track the client’s therapeutic progress, or lack thereof (Kettenbach, 1995). The priority of each objective is expressed either as a long or a short-term goal and corresponds to the problems list. Long-term goals are the expected final results of counseling, whereas short-term goals are those that can be accomplished within the next session or within a very limited time frame.
The fourth component is the progress notes, which are generally written using the SOAP format and serve to bridge the gap between the onset of counseling services and the final session. Using the SOAP format, the counselor is able to clearly document and thus support, through the subjective and objective sections, his or her decision to modify existing treatment goals or to fine-tune the client’s treatment plan. For example, if a client who has been in counseling for 4 months experiences the unexpected death of a loved one or is diagnosed with a potentially life threatening health problem, by recording this information in the progress notes the counselor provides justification/documentation for the sudden shift in therapeutic direction and is immediately able to address what is now the more pressing issue for the client.
The SOAP note format also provides a problem-solving structure for the counselor. Because SOAP notes require adequate documentation to verify treatment choices, they serve to organize the counselor’s thinking about the client and to aid in the planning of quality client care. For example, if the plan is to refer the client to a domestic violence group for perpetrators, the subjective and objective sections of the SOAP notes would chronicle the client’s history of physical aggression and violent behaviors, thus supporting the treatment direction. Although the SOAP format will not assure good problem-solving skills, it does provide a useful framework within which good problem solving is more likely to occur (Griffith & Ignatavicius, 1986). Thus, the intent of SOAP notes is multifaceted: to improve the quality and continuity of client services, to enhance communication among mental health professionals, to facilitate the counselor in recalling the details of each client’s case, and to generate an ongoing assessment of both the client’s progress and treatment successes (Kettenbach, 1995;Weed, 1968).
USING THE SOAP NOTE FORMAT
There are four components to SOAP notes. Data collection is divided into two parts: (S) subjective and (0) objective. The subjective component contains information about the problem from the client’s perspective and that of significant others, whereas the objective information consists of those observations made by the counselor. The assessment section demonstrates how the subjective and the objective data are being formulated, interpreted, and reflected upon, and the plan section summarizes the treatment direction. What follows is a description of the content for each section of the SOAP notes, a brief clinical scenario with an example of how this approach might be written, and a short list of “rules” to remember when writing case notes.
The data-gathering section of the SOAP format is probably the most troublesome to write because it is sometimes difficult to determine what constitutes subjective and objective content. The subjective portion of the SOAP notes contains information told to the counselor. In this section the client’s feelings, concerns, plans or goals, and thoughts, plus the intensity of the problem(s) and its impact on significant relationships in the client’s life are recorded. Pertinent comments supplied by family members, friends, probation officers, and so forth can also be included in this section. Without losing accuracy, the entry should be as brief and concise as possible; the client’s perceptions of the problem(s) should be immediately clear to an outside reader.
It is our opinion that client quotations should be kept to a minimum. First, when quotations are overused they make the record more difficult to review for client themes and to track the effectiveness of therapeutic interventions. Second, when reviewed by outside readers such as peer review panels, audit committees, or by a client’s attorney, the accuracy and integrity of the notes might be called into question. According to Hart, Berndt, and Caramazza (1985), the number of verbatim bits of information an individual is able to retain is quite small, 2 to 20 bits, with most estimates at the lower end. Other research suggests that information retained in short-term memory is only briefly held, 30 seconds to a few minutes at best, unless a very conscious effort is made to retain it (see Anderson & Bowers, 1973; Bechtel & Abrahamsen, 1990). This means that at the close of an hour-long counseling session, unless a quote is taken directly from an audio- or videotaped session, it is very unlikely that someone could accurately remember much information verbatim. In short, given this research, it seems a prudent practice to keep the use of quotations to a minimum.
If and when quotations are used, the counselor should record only key words or a very brief phrase. This might include client words indicating suicidal or homicidal ideation, a major shift in the client’s well-being, nonconforming behaviors, or statements suggesting a compromise in the type and quality of care the client will receive, such as when a client is unwilling or fails to provide necessary information. Quotations might also be used to document inappropriately aggressive or abusive language toward the counselor that seems threatening. Comments suggesting a potentially lethal level of “denial” should be documented. For instance, a father accused of shaking his 6-month-old daughter when she would not stop crying says, “I only scared her when I shook her, I didn’t hurt her.” Because the child’s life might be in jeopardy should the father repeat his behavior, his comments need to be recorded. For example, the counselor might write: “Minimizes the effects of shaking infant daughter. States, `I only scared her.’”
It is also important to document statements that suggest the client may be confused as to time, place, or person, or if he or she is experiencing a sudden change in mental status stability or level of functioning. For example, if during the session the client suddenly seems disoriented and unable to track the conversation, this information needs to be noted. To assess the client’s mental status, the counselor might ask the client the name of the current U.S. president. If the client responds incorrectly, this discrepancy should be noted in quotations within the client file.
Finally, a client’s negative or positive change in attitude toward counseling should be chronicled because it serves as a marker in the assessment of counseling effectiveness. A statement such as “Therapy is really helping me put my life into perspective” could be written as “Reports `therapy is really helping.’” This information is especially important if the client was initially resistant to therapy. The goal is not to give a verbatim account of what the client says, but rather to reflect current areas of client concern and to support or validate the counselor’s interpretations and interventions in the assessment and plan sections of the SOAP notes.
Given the open nature of client files to other health care professionals and paraprofessionals (e.g., certain managed care personnel), the counselor should be mindful of the type of client and family information included in the client’s record. Unless insidious family life and political, religious, and racial views are the focus of the problem(s), secondary details of such views should be omitted (Eggland, 1988; Philpott, 1986). The counselor should not repeat inflammatory statements critical of other health care professionals or the quality of services provided because these comments may compromise the client’s care by antagonizing the staff or might be interpreted as malicious or damaging to the reputation of another. Rather than using the names of specific people when recording the session, the counselor might use general words such as a “fellow employee” or “mental health worker,” and briefly and concisely report the themes of the client’s complaint(s). In addition, the names of others in the life of the client are typically unnecessary to record. It is important to remember that the names the client mentions during counseling (with few exceptions) are not a legitimate part of the client’s care and, as such, should be omitted from the client’s file.
The content in the subjective section belongs to the client, unless otherwise noted. For brevity’s sake, the counselor should simply write, “reports, states, says, describes, indicates, complains of,” and so on, in place of “The client says.” For instance, instead of writing, “Today the client says `I am experiencing much more trouble at home–in my marriage–much more marital trouble since the time before our last session,’” the counselor might write “client reports increased marital problems since last session.” Also, because it is implied that the counselor is the writer of the entry, it is not necessary for the counselor to refer to himself or herself, unless it is necessary to avoid confusion.
In a word, the”objective” portion of the SOAP format should be factual. It is written in quantifiable terms–that which can be seen, heard, smelled, counted, or measured. There are two types of objective data: the counselor’s observations and outside written materials. Counselor observations include any physical, interpersonal, or psychological findings that the counselor witnesses. This could consist of the client’s general appearance, affect and behavior, the nature of the therapeutic relationship, and the client’s strengths. When appropriate, this might include the client’s mental status, ability to participate in counseling, and his or her responses to the process. If they are available, outside written materials such as reports from other counselors/therapists, the results of psychological tests, or medical records can also be included in this section.
The counselor’s findings are stated in precise and descriptive terms. Words that act to modify the content of the objective observations, such as “appeared” or “seemed” should be avoided. If the counselor feels hesitant in making a definitive observational statement, adequate justification for the reluctance should be provided. The phrase as evidenced by is helpful in these situations. For example, one day the client arrives and is almost lethargic in her responses and has difficulty tracking the flow of the session. This behavior is markedly different from previous sessions in which the client was very engaged in the counseling process. When questioned, the client denies feeling depressed. In recording this observation, the counselor might chart, “Appeared depressed, as evidenced by significantly less verbal exchange; intermittent difficulty tracking. Hair uncombed; clothes unkempt. Denies feeling depressed.”
When recording observations, counselors should avoid labels, personal judgments, value-laden language, or opinionated statements (i.e., personal opinion rather than professional opinion). Words that may have a negative connotation, such as “uncooperative,”"manipulative,”"abusive,”"obnoxious,”"normal,” “spoiled,” “dysfunctional,” “functional,” and “drunk,” are open to personal interpretation. Instead, record observed behaviors, allowing future readers to draw their own conclusions. For example, one should not record, “Client arrived drunk to this session and was rude, obnoxious, and uncooperative.” Instead, one should simply record what is seen, heard, or smelled, for example: Consider, “Client smelled of alcohol; speech slow and deliberate in nature; uncontrollable giggles even after stumbling against door jam; unsteady gait.”
The assessment section is essentially a summarization of the counselor’s clinical thinking regarding the client’s problem(s). The assessment section serves to synthesize and analyze the data from the subjective and objective portions of the notes. The assessment is generally stated in the form of a psychiatric diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders, text revision (DSM-IV-TR; American Psychiatric Association, 2000) and is included in every entry. Although some counselors resist the idea of labeling their clients with a DSM-IV-TR diagnosis, third-party payers and accrediting bodies such as the Joint Commission on Accreditation of Hospitals require that this be done. According to Ginter and Glauser (2001), “Ignorance of the DSM system is not congruent with current expectations concerning counseling practice” (p. 70).
The assessment section can also include clinical impressions (i.e., a conclusion lacking full support) that are used to “rule out” and “rule in” a diagnosis. In more complex cases, in which insufficient information exists to support a particular diagnosis, clinical impressions work much like a decision tree, helping the counselor to systematically arrive at his or her conclusions. More important, when clinical impressions are used and stated, they enable outside reviewers and other health professionals to follow the counselor’s reasoning in selecting the client’s final diagnosis and treatment direction. When writing clinical impressions, counselors should identify them as such. For the sake of clarity, the relevant points from the data sections should be summarized. Doing this will assist the counselor in formalizing a tentative diagnosis and will demonstrate to outside reviewers the sequence of logic used to arrive at the final diagnosis.