Most therapists keep some form of notes to record patient encounters, keep track of important information, and monitor progress. Therapists who contract with insurance companies must write notes documenting each session.
What should be included in a therapy note, and how do you balance confidentiality with the need for accurate record-keeping? While there is some variation in how therapists keep and use notes, there are also standards and legal considerations to keep in mind when writing therapy notes.
SOAP notes
The field of psychology loves acronyms, and “SOAP” notes are a prime example. Each of the four letters in the word SOAP corresponds to a type of information that should be included in a therapy note: subjective, objective, assessment, and plan. The SOAP template helps the therapist to distill a 45-minute session into the most essential facts, keeping notes concise and professional.
Subjective– Subjective refers to information that the patient shares directly. It could be an account of their mood, functioning, or a significant event that occurred. To protect confidentiality, it is best to avoid quoting the patient directly. Instead, summarize their report using clear and concise language.
Example: Patient-reported low energy and difficulty concentrating this week.
Objective– Objective refers to factual information …
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