Progress notes
SOAP Note
The most widely used progress note. Separates what the client reported from what you observed, then your assessment and plan.
What it is
SOAP keeps four kinds of information apart: what the client told you, what you observed, what you make of it clinically, and what happens next. Because it's so widely recognized, a SOAP note reads clearly to supervisors, payers and other providers alike.
When to use it
- You want a format nearly every reviewer and EHR recognizes
- You like separating the client's report from your own observations
- Sessions where measures or observable change matter to the record
Sections
What Tidemend writes in each section. You can rename, reorder or adjust any of these in a custom template.
Subjective
The client's self-reported mood, concerns, symptoms, stressors and events since the last session, using brief paraphrase or short quotes.
Objective
Observable data: appearance, affect, behavior, speech, engagement and any measures administered during session.
Assessment
Clinical interpretation: progress toward treatment goals, response to interventions, changes in symptoms and current risk level.
Plan
Next session date/frequency, homework or between-session tasks, referrals, and what will be addressed next time.
Draft your next SOAP note with Tidemend
Record, dictate or type the session and get a draft in this format, ready to review, check and sign.
