Writing good SOAP Notes

SOAP Notes is a system for charting clinical notes. It is used both for mental and physical health. The letters stand for Subjective, Objective, Assessment and Plan. This format works well for keeping notes while doing neurofeedback. When you are doing an Intake session, we also recommend that you put your notes on the SOAP Notes tab. You will return to this tab regularly so they will be handy to review. You will have to enter the date for the Intake session. All the other dates  for the session are automatically entered using the date on the Sessions tab. 

Subjective

Subjective is what the client reports when they start the session. We suggest that this be somewhat open-ended but it is helpful to ask about the following: 

Were there any positive things to report? 

Were there any negative things to report?

What challenges arose since our last session?

How do you feel you managed them? 

One purpose of this line of inquiry is to get a broad view of both positive and negative things that happened so you can think about how you continue with or make changes to your protocols.  You can go here for recommendations on how to interpret the client’s report in terms of revising the protocol.

Another purpose of these questions is to help guide the client to become a better reporter, especially to be more specific in their reporting. We are not asking the client to tell us what we may want to hear. Rather, to give you accurate enough information that you can use in running the session. Clients who report nothing has changed when clearly things have changed can mislead you to jumping from one protocol to another. On the other hand, clients who report huge shifts from session to session are helpful unless something amazing or disastrous happens. With neurofeedback, the tendency is for concerns to improve gradually. Big shifts are often caused by what might be referred to as “my dog died” or “I just won the lottery”. The purpose of asking how they managed is to put external events in context and smoothe out the reporting. 

Objective

Objective is what you see and do in the session. If you are working on finding the optimal training frequency, you can enter each training frequency and the client's response. You can enter what you physically observe as well as what the client tells you. 

Assessment

Assessment is what you make of what is happening. It can be about why the client had the reaction they did, whether you are making progress, what needs to be added to the protocol, etc. Areas to consider are: 1) Are you working with good information from the client? 2) Are you at the correct training sites? 3) Is it time to add or change a site or continue without change? Remember that if you do change sites or the training frequency, it is better to change just one per session so you better understand what caused what. 4) Are you at the optimal training frequency? Look at the chart on indicators that the training frequency is too high or too low. 5) Do you need to revise the phrasing of the concern to get better reports?  You can’t delete a concern once it has been saved, but you can reword it. Remember, to make the change stick you have to go to Extensions>Results Tracking System>Save Changes on Concerns & Protocols. This will cause the concerns that were just selected to appear on the Sessions tab. Also, if you haven’t filled out all 8 concerns, you can add a new concern at a later session. Just remember you have to save the change for it to appear on the Sessions tab. 

Plan

    Plan is what you intend to do at the next session. The reason for writing that now rather than waiting is that now you remember all the details. When the client walks into the next session, you will likely have forgotten most of the information. It can be helpful to write a conditional plan such as, “if such and such happens, consider doing such and such and if this and this happens, consider doing this and this.” 

    You do not have to wait until the session is over to write everything down. You can write while the client is training and when they are finished, so are you. That is a great feeling.