3 Tips to Write Progress Notes

Introduction

As a health professional, knowing how to write a progress note is important. 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:

• Subjective
• Objective
• Assessment
• Plan

Now that we know the four parts, how are they applied in a clinical setting?

• The subjective element of a SOAP note is what the individual shares with their health professional. 
• The objective piece is what the health professional determines through a physical exam, laboratory results, or imaging. 
• An assessment is when the health professional provides a diagnosis. 
• The plan 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 establish the proper order of the story. In the case of the individual with hip pain, the health professional might discover a visit to the gym preceded the injury. Now we have a clue!

At first, the individual’s story might be a bit out of order. In describing their pain, the person 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 will 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 issue. Every time the patient says, “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.

Establish your uncertainty in writing. If you’re not sure about something, add that to your assessment. Use modifiers: “This seems possibly to be depression, but other things we should consider would be: hypothyroidism or vitamin B12 deficiency.”

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 important?

A SOAP note serves three important functions: a communication tool, a legal document, and a contract between the patient and provider.As a communication tool
A 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.

As a legal document
A SOAP note is also a legal document between the health professional and insurance companies.

As a contract between patients and health professionals

Last but not least, a SOAP note serves as a contract between the health professional and the patient or other individual seeking help. It’s an important tool for establishing a shared understanding of the potential problem, and the pathway to good health. Be as specific as possible in this contract.

Conclusion

Alright, as a quick recap… The three tips for writing a really good progress note are:

1. Write a good story
2. Remember that the diagnosis is a label
3. Write a specific plan

Now, SOAP up those hands and get writing!