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The therapy assessment section of a SOAP note is the section where you need to highlight why your skill was needed that day. It doesn't need to be paragraphs long, but avoid repetitive assessment phrases. Use the documentation templates for strategies for typing better assessments in less time.

Your diagnostic plan may include tests, procedures, other laboratory studies, consultations, etc. Your treatment plan should include: patient education, pharmacotherapy if any, other therapeutic procedures. You must also address plans for follow-up (next scheduled visit, etc.).

Plan: The last section of a SOAP note is the plan, which refers to how you are going to address the patient's problem. It may involve ordering additional tests to rule out or confirm a diagnosis. It may also include treatment that is prescribed, such as medication or surgery.

Introduction. The Objective (O) part of the note is the section where the results of tests and measures performed and the therapist's objective observations of the patient are recorded. Objective data are the measurable or observable pieces of information used to formulate the Plan of Care.

Writing a SOAP NoteSelf-report of the patient.Details of the specific intervention provided.Equipment used.Changes in patient status.Complications or adverse reactions.Factors that change the intervention.Progression towards stated goals.Communication with other providers of care, the patient and their family.

Tips for Effective SOAP NotesFind the appropriate time to write SOAP notes.Maintain a professional voice.Avoid overly wordy phrasing.Avoid biased overly positive or negative phrasing.Be specific and concise.Avoid overly subjective statement without evidence.Avoid pronoun confusion.Be accurate but nonjudgmental.

The SOAP format Subjective, Objective, Assessment, Plan is a commonly used approach to. documenting clinical progress.