In writing therapy SOAP notes or progress notes it is important that we keep emotions or opinions out of the notes.
Keep these things in mind:
- Record fact not opinion. Avoid words that are inherently subjective
- Don’t say ” Child was bored ” rather say ” Child yawned and squirmed in the chair during activity”.
- Record enough detail to paint a picture of what was going on.
- The child ran quickly around the room bumping into furniture.
- Don’t attribute feelings instead describe what you were seeing.
- Don’t say the child was bored say “Child yawned looked around the room.”
- Don’t say the child loves being read to say “He participates when stories are being read by pointing to objects or pictures.”
- Don’t suppose a reason a child was doing something
- Don’t say child wanted to get out of doing homework say ” Child left worksheet on the table.”
Some other examples:
- She appears to have some hyperactive tendencies and trouble focusing on the task at hand.
- Instead say child got up and down from the table, played with items in front of her and asked the therapist many unrelated questions.
- Jennifer was more comfortable in the second session, allowing her to be more outgoing.
- Instead say ” Child smiled and engaged in more back and forth conversation including asking this therapist questions.”
Examples of great Subjective information:
Upon first meeting the clinician, Abe immediately asked the clinician “no blowing papers?” several times, a behavior that was listed on his social behavior map from the previous semester.
Declan arrived on time to the session. He was smiling and laughing with clinician while entering the clinic room and continued for the duration of the session. He expressed great interest in the use of Braidy and required occasional direction to sit back in his seat while the working with Braidy. Declan responded well to the token system as he remained in his seat after receiving his smile tokens. Declan became more focused after his breaks as seen in his decrease in interruptions during the story reading.
Shannon engaged in pleasant conversation with the clinician upon entering the therapy room. She noted that she only had one week of school left but was nervous about her final exam the next morning. Despite these nerves, Shannon was fully engaged in the drill games played in the session as seen her reminders of the rules of mancala and laughing as she and the clinician knocked down the Jenga tower. Shannon willingly produced all the targets words incorporated into the game and repeated words with no opposition when asked by the clinician. Shannon concluded the session with more pleasant conversation with the clinician she left the therapy room.
Your turn: How would you change these? Identify the opinion and state how to say it more objectively.
- When Charlie does not immediately know the answer, he becomes anxious and begins self-talk.
- Sam was happy upon entering the therapy room and excited to see what was on her schedule for this session.