Clients SOAP records for therapists using appointment systems

Patient SOAP Records

SimplyBook.me has added a new custom feature that allows users/therapists to keep SOAP (text) records about clients/patients. The records are timestamped giving the therapist a perfect opportunity to track the progress of patients throughout the lifespan of their relation. Remember that always when there is delicate information, the HIPAA patient custom feature should probably also be activated.

The SimplyBook.me users may of course find various other purposes for this new feature but the basic purpose of the SOAP records is to keep track of the client’s condition and follow their progress after each client session and to track the effectiveness of treatments and aid to decide on future therapies and techniques.

(S)UBJECTIVE

The first part of the SOAP record is subjective observations. The client describes verbally things such as:

• How they feel
• History of symptoms
• Details about what hurts
• How this is affecting their life
• If something makes them feel better or worse

The therapist can ask the patient for a rating on his condition so that he can use this at later times to evaluate the progress.

(O)BJECTIVE

Here the therapist looks at the patient condition and tries to see if he can see visible effects on the patient because of his condition. This can be factors like:

• Muscle Spasms
• Breathing Patterns
• Effects on the patient’s posture
• Mobility
• Swelling
• Muscle Texture
• Any weaknesses of limps
• Movements of joints
• Color changes on skin
• Temperature

Other conditions may need to be evaluated depending on the provider’s profession

(A)SSESSMENT

The therapist evaluates if there are any results of the treatment such as changes in posture and range of motion. The client condition after treatment can also be ranked.

(P)LAN

The plan part of the SOAP record should include forward thinking measures of what recommended actions should be for the client. This can consist of giving the client exercises to perform until next appointment, the frequency of appointments, and potentially what the therapist is planning for the next meeting of the client.

Remember to always inform and have your client’s or patient’s consent when you are keeping delicate personal information about them.