Practitioners use various methods for writing case notes. Below is one example of a method by CM Working Group which may be helpful in fulfilling report writing to a standard expected by the NMC.
Example of SOAP Notes
S = Subjective
O = Objective
A = Assessment
P = Plan
What the client (or significant other) tells us about their condition,
Example 1: Client describes feeling very tired in the morning and not able to get out of bed until 11 a.m. after starting new medication and it is impacting ability to work. Worried about not having income.
What you observe or find during the medical case management visit.
Example 1:Client yawning during noon appointment appears more unkept than usual, and speech is more slow and clipped.
The Occupational Health Practitioner’s opinion or interpretation of the client’s situation as reported and you observe. The conclusions made in the assessment are more than a restatement of the problem as it determines whether or not the situation can be resolved.
Example 1: Appears that client is having difficulty with new medication. Client committed to finding a different way to manage the difficulty.
What do the client and Practitioner want to do to resolve the issue or situation? How will it be accomplished? Who will do what part of the service? This can often be incorporated into the care plan.
Example 1: Listen to concerns of client regarding change in energy level. Rule out other causes of exhaustion (e.g. substance use, grief, other mental health concern, etc.). Discuss with patient and doctor other methods for taking medication to not impact sleep and work function. Discuss referral to mental health or substance abuse support. Explore work options to avoid discipline for tardiness, etc.
This is one method of recording notes that are comprehensive. Your notes do not have to be done in this format, but should include a systematic process to capture, what the concern is, what is observed by the provider, what the assessment is and what’s the plan to address the issue.
The goal is to be concise, specific and accurate so anyone following up on client care would be able to clearly understand what is going on with the client and what the intended next steps are for each to respond