Clinical Documentation & SOAP Notes
For providers taking appointments that are covered by patients’ insurance—such as medical massage or physical therapy—clinical documentation like SOAP notes are a key component of the treatment and claims process. Detailed documentation allows a patient’s care team to better understand their condition and track their progress.
For future practitioners who work with your patient, your documentation can help inform their treatment choices and enhance the patient’s continuum of care. This documentation is also a crucial factor in health insurance processing—it helps ensure the patient will have their treatment covered by their plan.
What Does “SOAP” Mean?
The SOAP system is designed to easily capture an assessment of the patient’s condition, an explanation of their treatment, and a plan for achieving their recovery goals.
SOAP stands for Subjective, Objective, Assessment, and Plan. In some instances, you’ll also fill out a section detailing Treatment.
The Subjective and Objective portions of an evaluation take place at the start of an appointment, before you’ve begun treatment. You’re collecting information that will inform your therapeutic choices for the treatment you’re about to provide.
The Assessment and Plan portions are completed after a session has ended, since they contain information gathered during treatment, along with your future recommendations.
“SOAP” In-Depth
The Subjective entry consists of information the patient gives you. That could include an injury they’ve experienced, pain they are feeling, the severity of pain, and how it might affect other areas of their life, such as sleep or daily task performance.
Avoid adding your own observations or interpretations here—this is the patient’s opportunity to tell his or her own story as they experience it. The Zeel Provider App streamlines the Subjective entry with a series of evaluation tools to document the patient’s condition.
The Objective entry consists of your impartial observations of the patient’s condition. In a therapeutic massage context, this could include characteristics such as posture, range of motion, or soft tissue tension.
The Assessment section is completed immediately after the treatment has ended. Here you’ll summarize your overall findings, based on your prior evaluations and the treatment you just provided. Note how the patient responded to this particular treatment and how they are progressing overall. You may also comment "Patient progressing as expected" when there is no significant change.
The Plan portion of your SOAP notes looks forward. It should include steps to be taken in the patient’s course of treatment, such as future treatment recommendations or changes to an existing course. Think of your plan entries in terms of specific and measurable goals.
Note that in a patient’s initial evaluation, the plan should be more detailed, as you’re planning for their full course of treatment. Follow-up plan notes can be shorter, and may be as simple as continuing the current plan of care towards stated goals.
If you are required to fill out a Treatment section, describe the treatment you just provided. You should include specific modalities or techniques, the exact body parts treated, and which side(s) of the body you worked on.