Using a pre-determined framework in your notes will help you improve the quality of your client records.

One of the more popular methods for creating documentation is to take S.O.A.P. notes. Physician Lawrence Weed originally developed this four-pronged approach to notetaking. Today, the S.O.A.P. method is a highly effective communication tool to document client progress, plans, and interventions.

The SOAP note-taking framework includes four elements that correspond to each letter in the acronym— Subjective,Objective, Assessment, and Plan.

These four stages of note-taking offer a proven standard for gathering and storing the information necessary for complete and professional client notes. Let's examine each category in detail and drill down on what you need to include in a SOAP note. 

Subjective

The first step is to gather all the information you can about what the client shares about their issue, presenting topic, or concern. The client will tell you about their experience, impacts, and what they perceive to be their needs and goals for coaching. It's crucial to record the client's words rather than paraphrasing them, so you develop the most accurate insight into their presenting issue or concern.

The Subjective category is an appropriate place to list any comments made by the client, their family members, their significant other, or their caretakers. This category is the foundation for the rest of your notes, as well as your coaching plan. Gathering and recording the most quality information possible is paramount to the other note-taking categories that follow. 

Gathering content in the Subjective category covers the following areas:

• Onset: Determine when each presenting issue or concern first started.
• Location/Area: Find out the primary area of their discomfort or concern in their life.
• Duration: Learn how long the client been dealing with their presenting issue or concern.
• Character: Examine how the presenting issue or concern presents itself in their life.
• Alleviating or Aggravating Factors: What actions or interactions reduce or increase the severity or intensity of the presenting issue or concern.
• Radiation: Find out if the presenting issue or concern radiates or seeps into other areas of the client's life.
• Temporal Pattern: Document how the client's presenting issue or concern is manifest as patterns in their life.
• Secondary Impacts: Are there any secondary impacts that accompany the client's main presenting issue or concern.

With the client's presenting issue or concern documented, you can move to the next portion of the note.

Objective

The client's experience is fundamental to effective coaching, and making observations from an unbiased point of view is crucial. The Objective category of S.O.A.P. note-taking relates to describing what you are observing from a purely descriptive point of view in the words of the client.

Documenting the Objective category brings up the issue of separating the client's presentation of their issues or concerns from the coach's objective observations. Presenting issues or concerns are the client's subjective experience and objective observations are what the coach is seeing and experiencing in descriptive terms without opinion, interpretation, or bias.

It is important for the coach to actively look for any signs that complement or contradict information given in the subjective section of the note-taking.

Assessment

Both the Subjective and Objective categories previously recorded in the notes come into effect in the Assessment phase. The coach now documents their impressions and makes interpretations based on the information they've gathered. For an initial visit, the Assessment portion of your notes may or may not include an assessment based on the type and severity of presenting issues or concerns reported and coach observations.

The Assessment portion of S.O.A.P. notes covers an evaluation of how the client is progressing toward established their coaching goals. The Assessment will inform your current coaching trajectory as well as future plans, depending on whether the client is responding to coaching as expected.

It's essential to reflect on whether your client is showing improvement, maintaining improvements already made, is regressing, or demonstrating stagnation.

Like the other sections of S.O.A.P. notes, your Assessment should only contain as much information as necessary. Some Assessments will be more detailed than others, based on the complexity of the client's presenting issue or concern.

Sometimes this section of your notes will contain a few snippets of information like, "client is sleeping better, no change in the incidence of worry." In other situations, there are more elements to evaluate, and your Assessment portion of notes should extend to include all the appropriate information.

Plan

This is where the previous three categories of S.O.A.P. note-taking come together to help the coach determine the course of future coaching. The Plan section of your S.O.A.P. notes should contain information about:

• The coaching administered in today's session and your rationale for applying it.
• The client's immediate response to the coaching
• When the client is scheduled to return
• Any instructions you gave the client
• Goals and outcome measures for new problems or problems being re-assessed

Your Plan notes should include actionable items for each presenting issue or concern. If your client is experiencing multiple issues or concerns, the coaching notes should include separate plans for each presenting issue or concern.

The goal of the Plan category is to address all the specific issues listed in the Assessment. When done efficiently, the Plan sets a clear roadmap for the client's continuing coaching and is a window of insight for other professionals to continue coaching if needed. 

The Plan should be consulted on in all future coaching sessions and adjusted regularly based on the findings in the Assessment section.