Looking for a fast and easy way to keep track of your treatment notes? You need a SOAP Note template.
A SOAP note template is a file that’s designed to be replicated, so all your documents look the same. Using a template saves A LOT of time, so you don’t have to create your notes from scratch.
Plus, using a SOAP note template will make your notes more consistent, and look more professional.
There may be times when you need to share information with other healthcare providers or insurance companies. The documentation you provide must look professional.
A SOAP Note template provides a framework for sharing information in a clean, concise and professional way.
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Grab a high-quality SOAP note template for massage therapists, physical therapists, occupational therapists, multidisciplinary clinics, and more, free!
DOWNLOAD FREEA SOAP note should include treatment plans and benchmarks like the reason for the client’s visit, your observations, treatment details, and a game plan for subsequent sessions. You might also include a couple of personal notes where appropriate. Check out some how to write a SOAP note examples below.
This is where you record what the client tells you, including: health history, lifestyle, symptoms, etc. Example: Low back pain after long hours of sitting at her desk job. Sedentary lifestyle and no previous injuries.
This is where you record what you see and feel, including: p alpation, scars, bruising, postural distortions, ROM, etc. Example: She has a hard time standing up straight. Tension in QL. Weakness in glutes and hamstrings.
This is where you describe what the treatment consisted of and the client's progress. Record things like orthopedic tests, treatment methods and outcomes. Example: Deep tissue massage on the low back, hip flexors and glutes. She was able to stand up straight after treatment and reported no pain.
This is where you detail plans for the next session and recommendations for self-care. Example: Focus on hips and lower back next week. Recommended taking a walk on her lunch break to prevent things from stiffening up during the work day.
In addition to treatment notes, consider adding a section for personal notes. Results and relationships improve when you have a real connection with your clients. It’s a good idea to write down a couple things to jog your memory about who your client is. It could be a small detail about their life, family or work. Use it as a conversation starter next time you see them.
Is client paperwork adding up? Are SOAP notes taking too long? Do you wish you could be more precise with your client treatment plans?
It sounds like customizable SOAP notes software is right for you!
ClinicSense provides 3 types of SOAP notes templates to get you started + you can create your own from scratch with the customizable treatment note builder!
Now you can have a SOAP note for all scenarios - whether that’s a quick update or a fully detailed note and treatment plan.
Sign up with the button below to try the SOAP Notes free trial for 14 days.
Not into writing? Prefer pictures to words? Use this SOAP Note to quickly record your treatment notes with minimum fuss.
Prefer written notes, but don’t want to take the time to write them all out? Use this SOAP Note to create written notes fast.
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If you’re not ready for clinic management software yet, we can still help. We partnered with the American Massage Therapy Association to create this SOAP Note template. You can download it now, and start using it right away. Keep in mind, paper SOAP notes have their limitations.
