Understanding the four connections of the golden thread in SOAP notes is one thing. Knowing where they live inside an actual progress note, and which connections belong in Subjective versus Assessment, is what turns the framework into a daily documentation habit. This post picks up where Part 1 of this series left off. Part 1 laid out...
SOAP is an acronym for the four sections that structure a therapy progress note: S (Subjective): What the client reported about their symptoms, experiences, and functioning. O (Objective): What the clinician observed or measured during the session. A (Assessment): The clinical reasoning that connects diagnosis, treatment, and progress. P (Plan): The forward-looking treatment direction and...
Knowing what the four elements of medical necessity in SOAP notes require is one thing. Writing them into a progress note consistently, at the end of a full caseload day, is another. This is Part 2 of the series. This is where the concept tends to stall. Part 1 of this series laid out the four elements...
After Renee’s audit, the question I heard most often was a simple one: what does medical necessity in therapy notes actually mean, and how do you prove it? This is Part 1. Read Part 2: How to Write Medical Necessity Into Each SOAP Section. Most of us were trained to document clinical care. We learned...