SOAP Notes &
Other Progress Notes
KNR 279
Stumbo & Peterson, 2004
Shank & Coyle, 2002
Progress Notes
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Agencies may use different formats
for progress notes
Type of progress note may reflect
various forms of chart organization
Source Oriented/Narrative Format
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Narrative progress note
Does not have a specific structure
Information can be organized in any
logical manner
Note must still reflect progress
toward goals
Narrative Progress Note Example
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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.
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Also see Stumbo & Peterson, 2004, p. 322
Problem-Oriented Medical Record:
SOAP Progress Note
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S = subjective data
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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.”
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SOAP
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O = objective data
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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
SOAP
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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.
SOAP
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A = analysis (or assessment)
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Based on S & O
Can indicate progression, regression, or
no change in patient’s condition related
to problem
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A: Pt. has adequate social interaction
abilities and can interact with peers for
sustained periods of time.
SOAP
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P = plan
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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
SOAP
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P: Schedule two 1:1 sessions to reassess
conversation skills.
Enroll pt. in leisure planning group starting
4/11/07, MWF 10-11 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
SOAP(IER)
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I = intervention
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E = evaluation
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I: Stress Management, co-led with nursing
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
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R: Move from intermediate to advanced
leisure skills class.
Focus Charting: DAR(P) Progress Note
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Focus replaces problem from SOAP
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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
DAR(P)
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D = data
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A = action
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Description of actions taken by RT in form of
interventions or programs
R = response
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Subjective and/or objective information
Client’s response to interventions
Goals/objectives attained
Client outcomes
P = plan
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Next interventions
 See Stumbo & Peterson, 2004, p. 326
DAR(P) Example
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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.
Charting By Exception
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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
PIE Progress Notes
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P = problem
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I = intervention
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P: Sporadic attendance in assigned groups,
mumbling & telling CTRS to leave him alone.
Staff’s response to problems
 I: Spoke with client about behavior and will
set firm limits for hostile behaviors.
E = evaluation
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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.
DAIR Progress Note
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DA = data/assessment
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I = intervention
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Subjective or objective information
What was done for the patient
R = response
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Patient’s response to intervention or
interaction
DAIR Example
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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.
BIO Progress Note
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B = behavior
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I = intervention
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Notable behavior related to reason for
admission and is on treatment plan
Change in functioning
Staff interventions, including what was said,
done, and location
O = outcome
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Patient response to intervention, including
verbal and physical response
Patient response to education including
indication of understanding or skill
demonstration
Other Progress Notes
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There are also other forms of notes
Many are formulas
Some are combinations