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The assessment section is where you document your thoughts on the salient issues and the diagnosis (or differential diagnosis), which will be based on the information collected in the previous two sections. Summarise the salient points: ?Productive cough (green sputum)? ?Increasing shortness of breath?

Avoid vague language: Keep clear notes. SOAP notes are meant to be easy to follow, especially for other clinicians or providers who may need to read your notes. Overly descriptive language and irrelevant information can cloud your notes, which makes deciphering the notes more time-consuming.

Therapy Soap Note Example #1 Client reported ongoing worry and anticipatory anxiety. ... Client's speech was rapid and rambling. ... Client continues to experience severe symptoms congruent with their Generalized Anxiety Disorder diagnosis.

The Problem part of the note can be stated as the patient's chief concern. It may be medical, psychological, or functional. In some facilities, the pertinent history or medical information taken from the health record is included in the Problem area.

Length: SOAP notes should be 1-2 pages long for each session. Typically most sections are 1-2 paragraphs in all (up to 3 when necessary).

SOAP stands for Subjective, Objective, Assessment, and Plan. Each letter refers to one of four sections in the document you will create with your notes.

Tips for completing SOAP notes: Consider how the patient is represented: avoid using words like ?good? or ?bad? or any other words that suggest moral judgments. Avoid using tentative language such as ?may? or ?seems? Avoid using absolutes such as ?always? and ?never? Write legibly.

The order in which a medical note is written has been a topic of discussion. While a SOAP note follows the order Subjective, Objective, Assessment, and Plan, it is possible, and often beneficial, to rearrange the order.