Accurate and effective documentation is the backbone of quality care in any healthcare setting. Among the most widely used methods of clinical documentation is the SOAP note, a structured format that helps professionals record essential information about a client or patient in a logical and consistent manner. Whether you're a general practitioner, allied health therapist, or NDIS provider, mastering SOAP notes can significantly improve the clarity of your communication and the quality of care you deliver.‍

What Are SOAP Notes?

SOAP stands for Subjective, Objective, Assessment, and Plan. These four categories help structure clinical progress notes in a way that organizes both the client’s narrative and the clinician’s observations and decisions.

Originally developed in the 1960s by Dr. Lawrence Weed as part of the problem-oriented medical record system, SOAP notes have since become a global standard in healthcare documentation.

Why Are SOAP Notes Important?

SOAP notes serve several critical purposes:

• Consistency: Ensures all professionals document information in a unified format.
  
  
• Clarity: Clearly separates the client’s input from professional observations and interventions.
  
  
• Continuity of Care: Makes it easier for other clinicians to follow treatment progress.
  
  
• Legal and Compliance Records: Provides clear evidence of services delivered and rationale for clinical decisions.
  
  
• Funding Support: For NDIS providers, well-documented SOAP notes can help substantiate funding claims and compliance.
  
  

Detailed Breakdown of SOAP Components

1. Subjective (S)

This section includes information reported directly by the client, caregiver, or family. It reflects their perceptions, feelings, and experiences.

What to Include:

• Chief complaint (e.g., "I’ve been feeling very tired lately.")
  
  
• Pain levels or emotional status (e.g., anxiety, depression, confusion)
  
  
• Changes in appetite, sleep, or daily function
  
  
• Client concerns about medication or therapy
  
  
• Relevant social or environmental updates (e.g., changes at home)
  
  

Example:

"Client reports experiencing increased fatigue over the last 3 days and difficulty completing household tasks."

2. Objective (O)

This section presents measurable or observable data gathered by the clinician during the session.

What to Include:

• Vital signs (e.g., temperature, pulse, blood pressure)
  
  
• Physical observations (e.g., gait, muscle strength, posture)
  
  
• Behavioral observations (e.g., withdrawn, agitated)
  
  
• Test results or assessment scores
  
  
• Functional performance (e.g., time to complete a task)
  
  

Example:

"Client was observed taking frequent rests while walking. Blood pressure measured at 135/88. Scored 22/30 on the cognitive recall test."

3. Assessment (A)

This is the clinician’s interpretation of the situation, combining the subjective and objective data. It reflects professional reasoning and judgment.

What to Include:

• Diagnosis or problem summary
  
  
• Changes since last visit
  
  
• Progress toward goals
  
  
• Justification for continuing or changing treatment
  
  

Example:

"Client's fatigue appears to be increasing, impacting daily function. Mild improvement noted in memory recall. Progress is moderate but consistent with plan goals."

4. Plan (P)

This section outlines next steps based on the assessment. It should be specific, actionable, and trackable.

What to Include:

• Therapeutic interventions
  
  
• Medication or treatment changes
  
  
• Referrals
  
  
• Client education
  
  
• Next session focus
  
  

Example:

"Continue strength training exercises. Introduce energy conservation techniques. Monitor fatigue levels. Follow-up next session to evaluate coping strategies."

Best Practices for Writing SOAP Notes

Writing good SOAP notes takes practice and consistency. Here are some tips:

• Be concise but comprehensive: Stick to relevant details without rambling.
  
  
• Use clinical language: Avoid slang or vague terms.
  
  
• Document in real time: Write notes as soon as possible after the session to ensure accuracy.
  
  
• Be objective: Separate facts from opinions. Save interpretations for the Assessment section.
  
  

Avoid copy-pasting: Every session should reflect the client’s current condition.

SOAP Notes in the NDIS Context

For professionals working with NDIS participants, SOAP notes are essential tools to:

• Track progress against individual NDIS goals
  
  
• Communicate clearly with support coordinators and allied health teams
  
  
• Provide documentation for audits and compliance checks
  
  
• Substantiate the need for ongoing supports
  
  

Well-maintained SOAP notes can demonstrate a participant’s journey, justifying continued funding or adjustments in support plans. They also help ensure that each team member is on the same page regarding care delivery.

Leveraging Software for SOAP Notes

Many providers now use practice management software to streamline the SOAP note process. These platforms typically offer:

• Templates customized for different service types
  
  
• Auto-fill functionality for common entries
  
  
• Secure cloud storage that meets data privacy regulations
  
  
• Team access for multi-disciplinary collaboration
  
  

Choosing a platform with integrated NDIS support features can further ease the workload, ensure consistency, and improve outcomes.

Enhance Your Documentation with Imploy

To streamline your SOAP note documentation and overall care management, consider using Imploy—a comprehensive home care management software designed for NDIS providers. Imploy offers features like progress notes, incident management, custom forms, and compliance tracking, all within a secure and user-friendly platform. With Imploy, you can ensure accurate, efficient, and compliant record-keeping, allowing you to focus more on delivering quality care.

Conclusion

SOAP notes are far more than paperwork—they're a cornerstone of professional, person-centered care. Whether you’re treating a short-term injury or supporting long-term disability goals under the NDIS, the ability to document clearly and meaningfully is essential.

By understanding each section of a SOAP note and committing to best documentation practices, healthcare professionals can improve communication, enhance care quality, and meet both clinical and compliance standards with confidence.

‍