Best Practices for Completing SOAP Notes

As a member of the Zeel Provider Network, your ability to evaluate each patient and document their condition is an essential part of our promise to deliver the highest quality of care. The SOAP documentation format makes it easy for you to provide that expertise and support better outcomes for every patient.

Here are some tips to help make the documentation process efficient for you and valuable for the patient’s overall care:

• Complete your notes in a timely manner—ideally as soon as you finish the treatment, when the information is freshest in your mind.

• Keep it simple. Your documentation process should take no more than 5–10 minutes for an initial evaluation and 3–5 minutes for a daily note.

• You can use your phone’s talk-to-text dictation feature to enter notes in the Zeel Provider App, but always read them over before you submit your notes! Voice dictation is never 100% accurate.

• Do not “clone” (i.e. copy/paste) your notes. Documentation that is not changed or updated across multiple sessions gives the impression that the therapist is unattentive—or worse, uncommitted to the patient’s progress. Just like every patient is unique, every treatment is, too.

• This can’t be over-emphasized: Always review your SOAP notes before submitting them. Proofread them as you would any professional document—for clarity, spelling, and accuracy of information.