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A progress note is a cornerstone piece of a clinical documentation that social workers use to communicate with other members of the treatment team about the client’s progress. This note can also be reviewed by insurance companies for reimbursement as well as the client themselves, so it the notes have to be detailed enough to understand what is going but still maintaining client privacy.
For many social workers deciding what they should or should not include in a note is a dreaded task. It doesn’t have to be!
To take the guess work out of progress notes, I use the SOAP note format as an structure progress notes. This article will provide tips on how to write an effective social work progress note using the SOAP note format.
What is a SOAP note?
The SOAP note format is a common format for progress notes in social work. SOAP stands for Subjective, Objective, Assessment, and Plan. The subjective portion of the SOAP note should include information about the client’s current situation and how they are feeling. The objective portion should include information about the client’s observed mood and presentation. The assessment portion should include the social worker’s professional opinion about the client’s situation, including but not limited to reviewing interventions and progress. Finally, the plan portion of the note should include comments related to future treatment plans/goals as well as when the next session will be.
Why use the SOAP format for social work progress notes?
The SOAP format is a widely used method for documenting social work progress notes. This format provides a concise and structured way to document client progress and interventions. This structured format allows for a streamlined documentation process post session as well as facilitates treatment review when practitioners are preparing for the upcoming sessions and treatment planning.
There are many benefits to using the SOAP format for social work progress notes. First, the SOAP format is easy to use and understand. Second, the SOAP format allows you to document client progress in a concise and structured way. Third, the SOAP format can be used in both individual and group settings.
If you are looking for a simple, effective way to document client progress, the SOAP format is an excellent choice.
How to write an effective S (subjective) section
Most social work students find writing progress notes to be one of the most daunting aspects of therapy and fieldwork. However, with a few tips, any social worker can learn to write an effective S (subjective) section.
- Be as concise as possible. The S section should be no more than 1-2 sentences.
- This is the opportunity to use a direct quote from a client when describing the presenting problem.
- Note details such as start time and billing code
How to write an effective O (objective) section
This is the smallest section of the note where the client’s mood/affect are described.
Example: Client presents in a depressed mood with congruent affect
It is also important to include in this section a description of the safety risk if there is one. If there is no safety risk, be sure to include that too.
How to write an effective A (assessment) section
The assessment section, or A section, is the key component of a social work progress note. This section should be concise and clear, and state what the social worker and client hope to achieve during the session. Keep in mind that this section is the meat of the progress note and typically will be the longest section.
It is not necessary to include every single detail of what was said in the session, but rather focus on the therapist’s interventions and why the intervention was completed.
Most clients are utilizing insurance benefits for their therapy services. Insurance companies, when reviewing records, are looking to understand what they are paying for and how it is the most effective form of treatment for the client.
They do not care about the specific details the client is sharing. They do care about the symptoms that are being presented, if the symptoms changing as treatment progresses, and what evidence based interventions the social worker is providing to help the client move out of their diagnosed problem.
The assessment section should be written in a clear and objective manner. This means avoiding any personal bias or opinionated language. Again, this section is meant to described why and the how of treatment. Any personal opinions or theories should be saved for a psychotherapy note and is not to be included in the progress note.
Finally, the assessment section should be tailored to the specific client being seen. In other words, each client’s assessment should be unique to them and their individual needs. Though interventions may be standardized, there is still an art to the therapy process which personalizes treatment to each unique client. When the note is reviewed, it should should like it is specific to this person with XYZ problem, and not be a catch all for anyone and every diagnosis.
Example of being too specific: “Client said….”SPECIFIC QUOTE”. Then therapist said….”SPECIFIC QUOTE” [reads more like a transcript then a note]
Example of best practice: “Therapist held space for client to process emotions related to job related stressors and catastrophizing thinking associated with presenting anxiety.”
Example of too vague: “ Therapist listened to client vent about problems.”
By following these simple tips, social workers can ensure that their progress notes are well-written and informative. An effective assessment section can help provide valuable insights into a client’s current status and needs, which can ultimately lead to better care and improved outcomes.
In summary, when writing an assessment section, it is important to keep the following in mind:
- What are the goals of treatment?
- What does the evidence say about effective interventions for this population/problem?
- What are some reasonable objectives given the time frame?
- How will you know if the objectives are met?
Other things to consider are…
- Start with an action verb. For example, “Client reports feeling depressed.”
- Use client-centered language. For example, “Client feels supported by family.”
- Use objective language. For example, “Client appears agitated.”
- Avoid using value-laden words such as “good” or “bad.”
- Make sure your grammar and punctuation are accurate.
How to write an effective P (plan) section
In order to write an effective P (plan) section of a progress note, social workers should keep the following in mind:
- The P section should be brief and to the point.
- The P section should identify what the goals of treatment are and how these will be achieved.
- The P section should identify any resources that will be used in treatment, such as referrals to other agencies or professionals.
- The P section should identify any risks or potential problems that could arise during treatment and how these will be addressed.
- The P section should be realistic and achievable. It is important to set realistic goals so that clients can feel successful in their treatment.
- The P section should be reviewed and updated regularly as needed. Treatment plans may need to be adjusted as clients make progress or encounter new challenges.
If you are stuck on what to write or how to write your progress notes, the Practice Planners series are great resources for how to word your interventions. Below are the current publications that they have available:
- The Child Psychotherapy Progress Notes Planner
- The Adolescent Psychotherapy Progress Notes Planner
- The Adult Psychotherapy Progress Notes Planner
- The Severe and Persistent Mental Illness Progress Notes Planner
In conclusion, the SOAP note format for social work progress notes can be extremely beneficial when used correctly. This format allows for clear and concise communication between social workers and their clients, as well as providing a way to track goals and progress over time. When used correctly, the SOAP note format can be an invaluable tool for social workers and their clients.
Looking to enhance your SOAP note documentation? Use the tips listed above in conjunction with the 6 Minute SOAP Note Template to streamline your paperwork while maximizing quality clinical documentation. This template is great to use on its own, or can be copied and used in EHR systems such as Simple Practice.