3 Tips on How to Write Progress Notes
Dec 7, 2018
How to Write a Progress Note
As a health professional, it is important to know how to write a progress note. These progress notes are also known as SOAP notes. Why soap? Well, if you’ve written a progress note before, you know that SOAP is a useful shorthand for remembering the four components of note-taking:
Okay, we know the four components. What do they entail?
The subjective part of the SOAP note is what the individual shares with their health professional. The objective part is what the health professional determines through a physical exam, laboratory results, or imaging. The assessment part is when the health professional provides a diagnosis. Finally, the plan part is when the health professional decides what’s next.
What makes a great progress note? Here are three tips:
Tip #1: Write a story.
When an individual comes to a health professional with a problem, they will begin to describe their experience. For example, the individual might complain of worsening hip pain. It’s the health professional’s job to determine the potential cause of that pain. In listening to the individual’s subjective experience, it’s helpful to ask questions and to establish the true order of the story. In the case of the individual with hip pain, the health professional might discover the injury was preceded by a visit to the gym. Now we have a clue!
At first, the individual’s story might be a bit out of order. In describing their pain, the individual may only be describing bits of the story. During the history and physical exam, it’s important that the health professional lays out a story that makes sense. So, in the above example, the health professional would establish that the gym may have preceded the onset of the pain and supplement this information with their findings during the physical exam.
You want to tell a good story and you want it to make logical sense. This story should build up to a crescendo, which is the assessment.
Tip #2: Remember that a diagnosis is a label.
In writing the assessment, it’s important to remember that the diagnosis is going to stick with the individual over the course of many medical appointments. Let’s say a health professional has suggested the individual is depressed. That written label is not easy to shake off.
For example, this individual might be vitamin B12 deficient, but discovering this diagnosis is prevented by what appears in the progress note. In this case, “Diagnosis: Depression” can make it difficult to correctly assess the true problem. Every time they say, “I feel fatigued or tired,” the response will be, “You’re depressed.” Remember, when you write your diagnosis, other health professionals will see that label. It’s possible to cheat the individual out of getting the real diagnosis.
If you’re not sure about something, add that in your assessment. Use modifiers: “This seems possibly to be depression, but other things we should consider would be: hypothyroidism or vitamin B12 deficiency.” Establish your uncertainty in writing.
Tip #3: Write a specific plan.
The plan is the final part of the SOAP note. In writing the plan, it’s important to be specific. For example, something like “Plan to lose weight” is not very helpful. Instead, it’s useful to aim for something like “Reduce soda from three times a week to one time a week” or “Start drinking a healthy smoothie for breakfast.”
Why are Progress Notes (aka SOAP) important?
SOAP notes serve three important functions as:
- Tools of communication
- Legal documents
- Contracts between individual and health professionals
First, we know that the progress note is a way to communicate with other health professionals. The subjective, objective, assessment, and plan components of the note will inform the individual’s treatment during other medical visits. We also know that insurance companies want to see these SOAP notes.
Second, the SOAP note is a legal document between the health professional and insurance companies.
Finally, the third function of the SOAP note is to serve as a contract between the health professional and the individual seeking help. It is an important tool for establishing a shared understanding of the potential problem, as well as the pathway to good health. Be as specific as possible in this contract.
Alright, as a quick recap... The three tips for writing a really good progress note are:
- Write a good story
- Remember that the diagnosis is a label
- Write a specific plan
Now, SOAP up those hands and get writing!