The Importance of SOAP Notes in an EHR

The Origin of SOAP

Medical and behavioral healthcare lacked a scientific structure of documentation until the 1950’s when Yale University professor of medicine and pharmacology Dr. Lawrence Weed addressed the industry need. His problem-oriented medical record (POMR) was his first approach. Then he formulated the components of the SOAP notes used today (organization focus on Subjective, Objective, Assessment, and Plan).

In creating SOAP, Dr. Weed was inspired by a lack of notation synchronization of the art and science that forms modern healthcare. His aim was to make notes where practitioners could distinguish problem-solution relationships among patients’ conditions and treatment plans.

Today it’s used as the industry standard, spanning all behavioral and medical care forms. This is beneficial as a tool for client notes to be chronicled and shared among all providers involved in their treatment.

Benefits of SOAP in a Behavioral Health EHR

The SOAP benefits summation: having a standardized format for an Electronic Healthcare Records (EHR) platform. This supplies single-system access for shared practitioner-client notes, among all those involved in a patient’s care, throughout treatment lifecycles. These days, this could include medical care, therapy, counseling, and coaching professionals. Patients themselves also, can access their records and communicate with the practice through the EHR’s portal.

The most effective SOAP notes provide clear, straightforward language, avoiding the usage of professional jargon as much as possible. Taking a just-the-facts approach to encounter question-and-answer conversations and therapist observations yields the most credible information. Gathering and documenting data through all five senses adds a valuable thoroughness for diagnosis and treatment direction.

A utility factor of SOAP documentation is the personal protection, of both medical and therapeutic professionals as well as their clients. The security comes with having all necessary information about the client, available to the people involved in patient care, following HIPAA compliance. These notes facilitate the coordination and continuity of care.

The most beneficial documentation uses:

  • All relevant information with appropriate details.
  • Direct quotes from the patient or client.
  • Present tense writing (where applicable).
  • The distinction between hard data, facts, observations, and opinions.
  • Internal data collection consistency, with an organized and concise style.

With behavioral and mental health practice usage, client SOAP notes can signal follow-up actions to take with the EHR systems’ workflow, including follow-up patient encounters appointment reminders (in-person and telehealth), and medication orders and refills (eMAR). The reimbursement billing workflow is also automated through the platform.

Including patients’ medical records with mental health therapy information in their EHR documentation allows a more thorough view of encompassing patient care. This could include a physical health objective section with the subjective-objective assessment, and an objective assessment and plan.

Details including general patient information, physical examination notes, patient’s condition overview, and vital signs history are valuable assets to have at hand for continuing care. Assessment component and plan note with the objective component, and progress notes throughout the treatment lifecycle, can be included to create a detailed description of a client’s holistic health. Having all this data available from a single EHR source improves a practice’s collaborative abilities while reducing workflow costs.

EHR-managed SOAP notes provide:

  • Auto populating data from the EHR’s treatment plan section, including diagnosis, goal, and intervention notes.
  • Tracking and review of historical SOAP notes.
  • Time and cost savings by ending double data entry.

Keeping it Clean: SOAP and How the Behavioral Health 3-Minute Encounter Impacts Administration and Care

The importance of SOAP notes in an EHR is the enablement of care automation. The system intuitively chronicles the patient’s medical history and encounter notes, based on pre-configuredcommon complaints, conditions, and symptoms. While adaptable to each visit’s scenario, it cuts redundant data keying of consistent client information. This allows practitioners more interaction focus, with less time spent with repeated documentation.

This functionality creates the 3-Minute Encounter experience. The goal is to provide mental health professionals with the ability to chart each encounter experience with just 3-steps, completed in 3-minutes:

  1. A visit template is created for each client’s consistent traits.
  2. The common symptoms are selected and added through AI-driven automation.
  3. The provider gives the notes a quick review.

Clients appreciate superior care, and practitioners can reduce note bloat-induced burnout created by the typical 17-24 minute per encounter charting.

SOAP notes stored in an EHR will close the 3-Minute Encounter client care loop, enabling encounter scheduling, appointment reminders, medication subscribing, and billing.

See the 3-Minute Encounter in action here.

Contact an EHR Software Expert

At Qualifacts, we are committed to serving behavioral health, rehabilitative (PT/OT/SLP), and human services organizations by providing top-rated EHR solutions and services. Our team consists of seasoned professionals with hands-on clinical and administrative experience in these vital service areas. We understand the unique challenges you face and are here to assist you in selecting the most suitable solutions for your organization’s needs. Let’s kickstart the conversation that can transform your services. Complete this brief form to get started.