SOAP Notes Flashcards
1
Q
What does SOAP stand for?
A
Subjective; Objective; Assessment; Plan
2
Q
What are SOAP Notes used for?
A
They are used for medical documents.
3
Q
What does Subjective consist of?
A
Can consist of information obtained directly from the client or caregiver, direct quotes, medication changes, etc. Should NOT include recommendations or opinions.
4
Q
What does Objective consist of?
A
Therapist’s observations throughout session, clients engagement level and behaviors, affect, etc. Should NOT include complaints or opinions.
5
Q
What does Assessment consist of?
A
Consists of clinician discussing observed behaviors and collected data.
6
Q
What does Plan consist of?
A
Consists of next steps or plans for continuing programming; reports progress.
