This document will describe the differences between a SOAP Progress Note, Standard Progress Note and a Process Note and why you may choose to use one over the other.
SOAP Progress Notes
SOAP Notes are the de facto format for counseling session notes. The reason for such broad acceptance is because SOAP Notes are the standard in medical healthcare. Since there is some integration between the medical world and the counseling/psychological world, it stands to reason that counselors and therapists would naturally adopt the medical model for case note formatting. It may be essential for therapists to use the SOAP Note format if session notes are being shared in the medical community or the state you live in requires it.
The contents of a SOAP Note are broken down into four main areas:
Subjective – Client-based subjective feelings only. There should be no indication of objectivity as observed by the therapist. The Subjective portion of a SOAP Note often starts like: “Client says she feels...”
Objective – The Objective portion of the session note contains observable and identifiable characteristics and behaviors that the therapist sees (in spite of what the client says). It is common to use the phrase “It appears....” or “It is apparent....”
Assessment – Assessment should include clinical findings. It may be more philosophical than the Objective portion. This should tie everything (the Subjective and the Objective) together.
Plan – What do you plan to do with the information that has been gathered? More than just planning based on what has been observed in this single session, what is the broader Plan based on previous information gathered from previous sessions? How has the overall Plan been modified or adjusted by this new information? What needs to be done during the next session? What type of short-term goal can be achieved in the next three sessions? What homework has been given at the conclusion of this session to attempt to fulfill the Plan?
When using a SOAP note, nothing from a previous note carries over to the next note except the patient’s diagnosis. If you would like a patient’s objectives and goals to carry over from note to note use the Standard Progress Note.
Standard Progress Notes
Standard Progress Notes are often referred to as DAP Notes. They are much more structured than a SOAP Note. There are distinct areas such as Patient Presentation, Safety Issues, Interventions, Goals and Objectives. Unless the therapist is functioning in a medical setting wherein the sharing of case notes is important, the Standard Progress Note format may be more appealing and much easier to use. There are two main areas where you can document what occurred during each session.
Symptom Description and Subjective Report - Document the client's experience of symptoms and challenges since the last session. Symptom Description and Subjective Report may contain information communicated to the clinician and can include direct quotations of clients such as, "These visits are really helping me to strengthen my parenting" or "I think that these coping strategies are really working was able to concentrate at work all day."
Relevant Content - Report the measurable and observable information that you obtain during the session. Here, you may report behaviors that you observe, not just the behaviors you are targeting. There are two types of objective data: the provider’s observations and outside written materials. This is the section to document that which can be seen, heard, smelled, counted, or measured. You can document observations such as the mood and affect of the client here as well. The Relevant Content field is also where you can document specific information about conversations or interventions used during the session. The information in this field may answer questions such as, "How is the person is doing?", "What is the client's perspective about the problem?", or "What is the client’s opinion of the therapeutic intervention or service?" In this field, you may also document any information about the client given to you by someone else that you cannot verify but has an impact on the session or services.
The diagnosis codes and objectives that have not been achieved will carry over from one Standard Progress note to the next Standard Progress note.
Relevant Content - Report the measurable and observable information that you obtain during the session. Here, you may report behaviors that you observe, not just the behaviors you are targeting. There are two types of objective data: the provider’s observations and outside written materials. This is the section to document that which can be seen, heard, smelled, counted, or measured. You can document observations such as the mood and affect of the client here as well. The Relevant Content field is also where you can document specific information about conversations or interventions used during the session. The information in this field may answer questions such as, "How is the person is doing?", "What is the client's perspective about the problem?", or "What is the client’s opinion of the therapeutic intervention or service?" In this field, you may also document any information about the client given to you by someone else that you cannot verify but has an impact on the session or services.
The diagnosis codes and objectives that have not been achieved will carry over from one Standard Progress note to the next Standard Progress note.
Process Notes
Process Notes, sometimes referred to as Therapist Confidential Notes are the most basic of all notes. A Process Note is essentially a blank piece of paper that has very little structure to it. They are not recommended as a primary method of session recording especially since they do not include a “Plan” section, which is essential to continuity of the therapeutic relationship. They should not be used if the session is being billed to an insurance provider.
Process Notes however, can serve a very useful purpose in the counseling process. Process Notes are useful whenever an “event” or non-traditional session occurs wherein there were no clear objectives or “plans” involved in that session. This is most often seen in a non-scheduled session or in crisis situation. Another good use for Process Notes would be for phone calls that where not part of a regularly scheduled session. You could also use a Contact note for phone calls, email or text messages instead of a Process Note. If you want to take notes about conversations in the appointment, or document private thoughts or impressions, you may want to use a Process Note as well.
Process Notes however, can serve a very useful purpose in the counseling process. Process Notes are useful whenever an “event” or non-traditional session occurs wherein there were no clear objectives or “plans” involved in that session. This is most often seen in a non-scheduled session or in crisis situation. Another good use for Process Notes would be for phone calls that where not part of a regularly scheduled session. You could also use a Contact note for phone calls, email or text messages instead of a Process Note. If you want to take notes about conversations in the appointment, or document private thoughts or impressions, you may want to use a Process Note as well.