What Goes in a SOAP Note: A Section-by-Section Guide
What goes in a SOAP note, section by section: Subjective, Objective, Assessment, and Plan, the sign-vs-symptom rule, a full example, and mistakes to avoid.
Resources
Articles, conversations with clinic owners, and practical guides for running a great practice.
What goes in a SOAP note, section by section: Subjective, Objective, Assessment, and Plan, the sign-vs-symptom rule, a full example, and mistakes to avoid.
The 2027 Medicare Physician Fee Schedule proposed rule is here. See how it prices the new SLP codes, what reimbursement could change, and the comment deadline.
The articulation therapy CPT code 92507 is deleted in 2027. Here's the new timed speech sound production code family for articulation, apraxia, and dysarthria.
Billing combined speech and language therapy under the new 2027 SLP codes: when to use the combined code vs two base codes, time thresholds, and documentation.
CPT 92507 is being deleted January 1, 2027 and replaced by ten new timed SLP codes. Here's what's changing, what's still unknown, and how to prepare now.
Timed codes are coming to speech therapy in 2027. Here's what a defensible treatment-time record looks like and the audit triggers SLPs need to avoid.
The fluency therapy CPT code is changing in 2027. Here's how stuttering and cluttering treatment bills under the new timed SLP codes, with a worked example.
CPT 92507 is deleted in 2027 and language treatment gets its own timed code pair. Here's how the language therapy CPT code changes and how to document it.
A practical guide to medical necessity speech therapy documentation: what payers want, skilled vs. unskilled examples, and notes that hold up in 2027.
A practical guide to teaching students to use an EMR in a university clinic: access setup, scaffolded practice, the error path, and the supervisor feedback loop.
Timed CPT codes are coming to SLP billing in 2027. Here's how the 8-minute rule works, how minutes become units, and how it differs from the PT/OT rule.
Voice, upper airway, and resonance treatment move to one new timed CPT code pair in 2027. Here's what changes for SLPs and how to document it.
Supervising students in a training clinic? A practical guide to the oversight the rules require, feedback that builds skill, and a clean co-signing workflow.
Real physical therapy SOAP note examples for ortho, neuro gait, and low back pain, with ROM and MMT data, the reasoning behind each line, and a free template.
Real occupational therapy SOAP note examples for ADL, hand therapy, and pediatric sessions, with the clinical reasoning behind every line and a free template.
How to write physical therapy SOAP notes, section by section, with rules for each part, a strong Assessment formula, SMART goals, and defensible documentation tips.
Learn how to write DAP notes step by step: the Data, Assessment, and Plan sections, objective language, a required-elements checklist, and a full example.
How to write an occupational therapy SOAP note, section by section, with the rules for each part, a strong Assessment formula, SMART goals, and documentation tips.
HIPAA vs FERPA for university health clinics, explained: which law governs student records, when both apply, and what it means for how you document.
Picking an EMR for student-run clinics? Here's what actually matters: turnover-proof onboarding, continuity of care, HIPAA access, and interprofessional records.
DAP note examples for counselors, plus a reusable template, the three sections explained, and DAP vs SOAP, so your notes hold up in an audit.
Learn how to learn EMR systems without the overwhelm. A practical, step-by-step guide to EMR training for students and new clinicians.
Learning how to use an EMR? Here's a beginner-friendly walkthrough of the daily workflow, documentation, fixing mistakes, and what to expect in week one.
Northern Michigan University's speech clinic moved from paper and Google Docs to ClinicNote — a documentation system built for student training and supervision.
New Mexico State's speech clinic moved from email threads and Word docs to a single ClinicNote workflow. How they did it and what changed for students.
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