Medical documentation is a core component of treating clients at your holistic practice; better documentation leads to better patient outcomes and reduces overall patient risk.

But when it comes to certain types of medical documentation, like SOAP notes, there are some common mistakes that you should be wary of making. These mistakes will take up precious time and result in ineffective notes–that’s a lose-lose situation!

In this article, we’ll cover SOAP notes, the importance of medical documentation at your holistic practice, and some common mistakes we want to help you avoid.

Keep reading to learn more!

What Are SOAP Notes?

SOAP notes are a kind of medical documentation; initially, SOAP notes were developed for use in traditional medicine settings, like hospitals, but now SOAP notes are effectively leveraged in nearly every facet of the healthcare industry!

This template for comprehensively logging a client’s wellness journey includes for sections, each letter in SOAP stands for:

Subjective

In this section, you’d include information regarding how the patient subjectively feels and phrases they use to describe their internal experience. For example, does your client feel achy and sore when they get out of bed? Noting their subject experience is helpful for establishing their point of view and addressing their concerns.

Objective

The second section is where you’d document objective pieces of evidence pertaining to the patient’s condition. For example, if they have limited range of motion or if they’re sensitive to the touch on their lower back. These pieces of information must be able to be supported by objective statements and evidence.

Assessment

For the next section of your SOAP notes template, you’d elaborate on what type(s) of condition your patient might have, your reasons why, and provide updates on how the treatment plan is progressing over the course of your subsequent sessions. For example, you might note that the patient expresses a significant decrease in their pain level.

Plan

Finally, your SOAP notes conclude with a section discussing the plan of action you have for your patient. What are their immediate next steps? When will they return to your holistic practice for another session of treatment? These details are important to include in this medical documentation.

SOAP Notes and the Importance of Medical Documentation

Now that we’ve reviewed the general format of SOAP notes, let’s talk about the importance of them and medical documentation as a whole at your holistic practice.

These forms and notes capture important information in the moment and help establish a comprehensive analysis of your patient’s condition. Over time, these snapshots provide deeper insight into the patterns and waves that a client’s condition might demonstrate.

Thus, SOAP notes and other types of medical documentation help reduce patient risk by requiring you to evaluate multiple perspectives and put various details together to paint a bigger picture. Such improved outcomes are obviously a win-win for you and your patient!

Furthermore, having detailed records and a paper trail is beneficial to your holistic practice from a medical billing perspective–when you have detailed notes to back up your medical coding and billing claims, you have a better chance of getting reimbursed than if you were simply “winging” your medical coding.

Avoid These Common SOAP Notes Mistakes

There aren’t any shortcuts to good quality SOAP notes, but there are some pitfalls you can watch out for, like these common mistakes:

Mistake: Including statements without evidence to support them

Your SOAP notes should have sources and evidence to support them. This means that your notes should be unbiased and be an accurate reflection of what occurred during your session with the patient. For example, if a patient seems happy, then it would be smart to note what evidence you have for that statement, e.g., the patient was smiling and laughing.

Mistake: Saying the same thing in each of the SOAP note sections

Another common mistake people make is regurgitating the same information in each section of SOAP notes. This ultimately defeats the purpose of SOAP notes, which is to comprehensively interpret and analyze a patient’s condition.

Don’t include how the patient is feeling in your Assessment notes but do include how they describe their pain in the Subjective section! Keep a list of what each section is meant to cover handy until you know how to fill in each spot appropriately.

Mistake: Using general or vague language

While you shouldn’t spend hours writing your SOAP notes, it is important to include details and specifics in your report. A common mistake is making general statements or being too brief in your writing, which isn’t properly leveraging the SOAP notes format.

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