SOAP notes are maybe even the most accessible type of therapy notes in healthcare documentation. Many practitioners get confused when they need to choose between SOAP notes and progress notes. Progress notes have grown 60% longer in the last decade. This trend shows that clinical documentation needs more detail now.
Both formats help track client care but work differently in their structure and use. SOAP stands for Subjective, Objective, Assessment, and Plan. This framework gives healthcare professionals a clear way to document client progress. Progress notes can use different formats like DAP (Data, Assessment, and Plan) and BIRP (Behavior, Intervention, Response, and Plan). Each format meets specific documentation needs. DAP notes make the process faster by putting subjective and objective data together. They take less time to complete than regular SOAP notes.
Healthcare professionals need to know these documentation differences to maintain good care and follow record-keeping rules. The right format choice can make a big difference in tracking treatments and helping providers communicate better. This piece explains these key differences and helps practitioners pick the best format for their needs.
Dr. Lawrence Weed developed SOAP notes in the 1950s, and they've become the standard way to document patient information during healthcare visits. These well-laid-out notes work as a vital communication tool between healthcare providers and provide a framework for clinical reasoning.
SOAP stands for four distinct components that build a complete clinical documentation:
Subjective: This first section captures the patient's experiences, feelings, and concerns. Healthcare providers document information straight from the patient, including their main complaints, symptom history, and relevant personal details. Medical teams use the "OLDCARTS" format (Onset, Location, Duration, Characterization, easing/Aggravating factors, Radiation, Temporal factors, Severity) to organize this information in a clear way.
Objective: This part shows observable, measurable data collected during the visit. Vital signs, physical examination findings, test results, and other factual information that anyone could verify belong here. The objective section stays free from any interpretation.
Assessment: Clinicians blend subjective and objective information to create diagnoses and review patient status. This section shows the clinical reasoning and analytical thinking behind solving problems.
Plan: The last component maps out treatment strategies, next steps, and follow-up care. It lists interventions, medications, referrals, and patient education needed to tackle each identified problem.
SOAP notes have spread to mental health practice because of their clear format, though they started in medical settings. Medical notes focus on physical symptoms and clinical findings. Therapy notes, however, highlight behavioral observations, psychological assessments, and therapeutic interventions.
Subjective: "Client reports feeling more anxious this week. She said she felt more jittery and on-edge, and reports having more anxious thoughts that were harder to control."
Objective: "During the session, the client was fidgety, wringing her hands, and speaking quickly. She appeared to have difficulty concentrating."
Assessment: "Based on the client's reports and in-session observations, the client's anxiety has increased but continues to meet criteria for generalized anxiety disorder (GAD)."
Plan: "Recommended that client see a primary care physician. Client will continue coming to therapy once a week to treat anxiety through cognitive behavioral therapy (CBT)."
"Some practitioners may prefer to use DAP notes as they allow for the combination of both subjective and objective data in the Data section, streamlining the note-taking process by eliminating the need to separate the two types of information into distinct sections." — Dr. Cory Szybala, CEO and Founder of Zanda Health (Power Diary)
Progress notes are formal clinical documents that track a client's treatment experience through their healthcare visits. These structured records differ from personal clinical notes and document patient status, interventions, and progress toward treatment goals.
Healthcare professionals use several structured formats to document their work:
Narrative Notes give a chronological account of patient visits with more flexibility but less structure than other formats. Clinicians sometimes prefer this free-flowing style of documentation in certain situations.
DAP Notes (Data, Assessment, Plan) make documentation simpler with three sections instead of four. Therapists often choose DAP notes because they "allow for more subjectivity around elements of mental health that are less black and white."
BIRP Notes (Behavior, Intervention, Response, Plan) put the spotlight on client actions and responses. This behavior-focused format helps track observable changes and shows how well interventions work in therapy.
Basic Notes follow sessions chronologically through sections like Presentation, State, Assessment, Themes, Treatment, and Progress (PSATTP). This format gives professionals another way to organize their documentation naturally over time.
Therapy progress notes usually cover three simple categories:
Many other formats exist in healthcare settings, such as GIRP (Goal, Intervention, Response, Plan), PIRP (Problem, Intervention, Response, Plan), and DART (Data, Action, Response, Treatment).
Medical settings need detailed documentation that connects to diagnoses and medical necessity, especially for insurance. These notes should be objective, concise, and relevant.
Therapy notes often focus on behavioral observations and therapeutic relationships. Each clinician can adapt them to their specific approach and practice needs.
Addiction inpatient facilities need very detailed notes to track how treatments work and their outcomes. Electronic health records now make documentation more detailed, though this sometimes creates "note bloat" with extra information.
The main difference between SOAP notes and progress notes comes down to their classification. SOAP notes are a type of progress note. However, all but one of these progress notes use the SOAP format. Healthcare professionals can pick the right documentation method by understanding these differences.
SOAP notes use a strict four-part framework that separates patient-reported information from clinician observations. This clear division creates organized assessment and planning records. These records work well especially when you have multidisciplinary settings. Progress notes take a more flexible approach with formats like DAP notes. They combine subjective and objective information into a single "Data" section. This integration makes documentation more efficient as experiences and observations often overlap.
SOAP notes shine when detailed clinical reasoning and full documentation become essential. Medical teams prefer them for:
Progress notes like BIRP focus on behavioral tracking and work better for:
Research shows that structured documentation substantially improves electronic health record notes' quality. One study revealed a 12.8 point quality improvement after teams started using structured formats. All the same, DAP notes are a quickest way to document compared to SOAP notes. They need less time to complete by combining subjective and objective information under one heading. This proves helpful during routine follow-ups or straightforward cases.
"To speed up the process significantly, use EHR software and preconfigured note templates." — Dr. Cory Szybala, CEO and Founder of Zanda Health (Power Diary)
Healthcare providers must consider several factors that affect patient care and clinical workflow when selecting documentation formats. The right format needs to match specific healthcare contexts.
SOAP notes work best in acute care environments where complex clinical presentations need detailed clinical reasoning. Medical teams first developed these notes, and healthcare settings with multidisciplinary teams still use them extensively. These notes prove valuable when clients need team care with multiple professionals such as social workers, counselors, and psychiatrists.
Alternative progress note formats can streamline documentation better in long-term therapy settings. DAP notes take less time to write because they combine all session information instead of separating subjective and objective components.
Legal requirements don't specify a particular note format. Sessions just need proper documentation that suits the client's clinical needs. Insurance companies want standardized documentation that shows:
Progress notes should contain enough documentation to support claims. Payment denials can happen with incomplete or illegible records. Medicare needs progress notes at or before every 10th session.
We chose note formats based on personal preference, organizational requirements, and specific practice needs. DAP notes appeal to therapists who want to save time because they don't need to separate subjective and objective data.
Whatever format you choose, good documentation should:
Documentation is the life-blood of effective patient care and professional practice in healthcare. The choice between SOAP notes and other progress note formats can substantially affect clinical efficiency and treatment tracking. Medical professionals need to pick documentation methods that line up with their practice needs and clinical setting.
SOAP notes work best in multidisciplinary settings that need detailed clinical reasoning and thorough documentation. Their well-laid-out four-part format separates patient reports from clinical observations clearly. This makes them valuable tools for complex cases and first-time evaluations. On the other hand, DAP notes make things simpler by combining subjective and objective data, so they save time during routine follow-ups.
Regulations play a big role in documentation choices. The law doesn't require specific formats, but progress notes must have enough information to show medical necessity and justify ongoing care. Healthcare providers who fail to do this risk insurance claim denials and compliance problems that could hurt patient care and practice success.
Good documentation serves many vital purposes whatever format you choose. It will give a smooth transition of care between providers and legal protection through detailed record-keeping. On top of that, well-laid-out notes make team communication clearer and track patient progress over time objectively.
Healthcare professionals should pick a documentation approach that balances detailed clinical information with efficient workflows. Whether they use SOAP, DAP, BIRP, or another format, the focus must stay on creating accurate records that improve patient care and meet professional standards. The right documentation choice becomes a strategic decision that affects treatment quality, team communication, and practice success.
Q1. How do SOAP notes differ from other types of progress notes? SOAP notes follow a structured four-part format (Subjective, Objective, Assessment, Plan), while other progress notes like DAP (Data, Assessment, Plan) combine subjective and objective information. SOAP notes are typically more detailed and time-intensive, making them ideal for complex cases and multidisciplinary settings.
Q2. When should healthcare professionals use SOAP notes versus other progress note formats? SOAP notes are best for complex cases, initial evaluations, and multidisciplinary settings requiring detailed clinical reasoning. Other formats like DAP notes are more suitable for routine follow-ups and straightforward cases where time efficiency is crucial.
Q3. Are there legal requirements for using specific progress note formats? There are no strict legal requirements for using specific formats. The key is to ensure that sessions are documented appropriately, demonstrating medical necessity, progress toward goals, and justification for continued care. The notes should contain sufficient information to support insurance claims and meet regulatory standards.
Q4. What are the main advantages of using DAP notes over SOAP notes? DAP notes are generally quicker to complete as they combine subjective and objective data into one section. This streamlined approach makes them more time-efficient, especially for routine follow-ups or straightforward cases. They're often preferred by therapists seeking to optimize their workflow.
Q5. How do BIRP notes differ from SOAP and DAP notes? BIRP (Behavior, Intervention, Response, Plan) notes focus specifically on behavioral tracking and intervention effectiveness. They're particularly useful in therapy settings and for documenting clinical interventions. Unlike SOAP or DAP notes, BIRP notes emphasize client behaviors and responses to specific therapeutic techniques.
Reduce costs and improve your reimbursement rate with a modern, all-in-one clinic management software.
Get a Demo
.avif)
