1. SOAP Notes & Other Progress Notes
KNR 279
Stumbo & Peterson, 2004
Shank & Coyle, 2002

2. Progress Notes Agencies may use different formats for progress notes
Type of progress note may reflect various forms of chart organization

3. Source Oriented/Narrative Format
Narrative progress note
Does not have a specific structure
Information can be organized in any logical manner
Note must still reflect progress toward goals

4. Narrative Progress Note Example
Client attended 33% of scheduled recreation therapy groups (sports 4/5/07, fitness 4/6/07). Concentration is improving as client was able to focus on task for 10 minutes. Will continue with current treatment plan and incorporate daily reminders to increase attendance at recreation therapy groups.
Also see Stumbo & Peterson, 2004, p. 322

5. Problem-Oriented Medical Record: SOAP Progress Note
S = subjective data
Statements client makes about problem or course of treatment
Could also be family or friend statements
S: “I want to stay in my room. Leave me alone.”
S: “I feel like I am making better decisions.”

6. SOAP
O = objective data
Gathered by observation of client’s actions or behaviors
Must be stated in overt behavioral terms
Does not include opinions
Must only reflect behaviors that relate to the client’s problems or the initial treatment plan

7. SOAP
O: Pt. asked questions about transportation to the activity, ticket prices, food, and return time.
O: Pt. engaged in a 10 minute conversation with a peer and responded to questions about television shows.

8. SOAP A = analysis (or assessment) Based on S & O
Can indicate progression, regression, or no change in patient’s condition related to problem
A: Pt. has adequate social interaction abilities and can interact with peers for sustained periods of time.

9. SOAP P = plan Based on A Updates treatment plan
Indicates additional information that may need to be collected
Notes specific programs
Notes intervention techniques
Notes frequency and duration
Notes when plan will be reevaluated
Notes any new goals & objectives
Indicates referrals to other services

10. SOAP P: Schedule two 1:1 sessions to reassess conversation skills.
Enroll pt. in leisure planning group starting 4/11/07, MWF am for 3 weeks. New objective: After 1 week in leisure planning group, patient will accurately complete a planning sheet for his community reentry outing as judged appropriate by CTRS.
See Stumbo & Peterson, 2004, p. 324

11. SOAP(IER) I = intervention E = evaluation R = revision to plan
I: Stress Management, co-led with nursing
E = evaluation
Evaluates effectiveness of intervention
Includes patient’s response to intervention
Notes if goals or objectives were achieved
E: Pt. did not meet exercise goal of 3 times a week due to complications from infection.
R = revision to plan
R: Move from intermediate to advanced leisure skills class.

12. Focus Charting: DAR(P) Progress Note
Focus replaces problem from SOAP
Current concern or behavior, e.g., aggressive social behavior, pre-op teaching
Key word, e.g., activity tolerance
Sign or symptom important to treatment plan, e.g., suicide threat, poor personal hygiene
Acute change in condition, e.g., seizure, apathy
Significant events, e.g., family visit, community reentry
Could be problems or positive

13. DAR(P) D = data A = action R = response P = plan
Subjective and/or objective information
A = action
Description of actions taken by RT in form of interventions or programs
R = response
Client’s response to interventions
Goals/objectives attained
Client outcomes
P = plan
Next interventions
See Stumbo & Peterson, 2004, p. 326

14. DAR(P) Example Focus: Hallucinations
D: Mumbling to self during RT program on 4/23 and 4/24, pacing, unable to focus on task.
A: Provided verbal cues to remain focused.
R: Able to focus for 10 minutes with support but becomes agitated beyond 10 minutes.
P: Continue involvement in RT program to facilitate focusing on external stimuli. Gradually increase time requirements. Provide positive verbal comments for sustained attention.

15. Charting By Exception
Used when standardized clinical pathways (protocols) for a diagnostic category are used
Charting only occurs for exception to plan or outcome not achieved or outcome achieved earlier than anticipated
Must include date, what intended outcome was, explanation of why variance occurred, and plan to deal with variance
May be flow sheets

16. PIE Progress Notes P = problem I = intervention E = evaluation
P: Sporadic attendance in assigned groups, mumbling & telling CTRS to leave him alone.
I = intervention
Staff’s response to problems
I: Spoke with client about behavior and will set firm limits for hostile behaviors.
E = evaluation
Staff’s evaluation of how effective intervention was and future plans
E: Client responded to firm limits, apologizing for behavior. Will establish daily contact to facilitate rapport with CTRS.

17. DAIR Progress Note DA = data/assessment I = intervention R = response
Subjective or objective information
I = intervention
What was done for the patient
R = response
Patient’s response to intervention or interaction

18. DAIR Example
D: 80 y/o white male pacing in hallway. Pulling at door handle. Fretful. Grabbing at staff.
A: Pt agitated. Denies pain.
I: Reality orientation, redirection, diversion and comfort offered. Monitor for escalation. Decrease stimuli.
R: Cooperative. Redirects easily. Agreed to meet with CTRS in quiet alcove.

19. BIO Progress Note B = behavior I = intervention O = outcome
Notable behavior related to reason for admission and is on treatment plan
Change in functioning
I = intervention
Staff interventions, including what was said, done, and location
O = outcome
Patient response to intervention, including verbal and physical response
Patient response to education including indication of understanding or skill demonstration

20. Other Progress Notes There are also other forms of notes
Many are formulas
Some are combinations