SOAP Notes in ABA

SOAP Notes

SOAP notes are used across many medical fields, including ABA (Applied Behavior Analysis). SOAP is an acronym for:

  • Subjective
  • Objective
  • Assessment
  • Plan

Subjective (S)

  • Information gathered from and about the client.
  • Examples:
    • Current level of functioning.
    • Current complaints or concerns.
    • Direct quotes from the client or their caregiver.
    • Changes in medication.
    • Changes in family situation.
    • Anything else that could be impacting the client.
  • No opinions or recommendations are given in this section.

Objective (O)

  • Consists of the observer's observations.
  • Includes:
    • Client's general appearance and affect.
    • Behaviors observed during the session.
    • Engagement level.

Assessment (A)

  • Use clinical knowledge and combined information from the Subjective and Objective sections.
  • Give an overall impression of why you observed what you did in the Objective section.

Plan (P)

  • Plans for future interventions or adjustments to current interventions are laid out.
  • Progress and regression are reported.
  • Notes about what worked and did not work in this session.

Example SOAP Note

S:

  • F. Joshua arrived late, delaying the start of the session by 10 minutes and reports not really wanting to have today's session.
  • Parents reported that Joshua did not sleep well last night and has been yawning a lot today.

O:

  • Joshua appeared tired, frequently yawning and putting his head down.
  • Joshua greeted the technician with a smile and sat down quickly to work on writing his name.
  • Joshua wrote his name correctly three out of three times, then threw the pencil and said he was done.
  • Throughout the session, Joshua threw items and stated that he was done six times.
  • When the therapist prompted him to ask for a break, he did so on four out of five opportunities.

A:

  • Joshua expressed being tired today and did exhibit some throwing behavior.
  • The antecedent appears to have been being asked to do a non-preferred repetitive task.
  • Joshua did successfully ask for a break when he was prompted and used FCT (Functional Communication Training) to express when he wanted to be done with some task.
  • Overall, Joshua's throwing behavior was consistent with previous sessions.

P:

  • Next session, the technician will work on prompting Joshua to ask for breaks before Joshua gets bored or tired of doing a task.
  • Instruct parent how to do the same to decrease throwing behaviors observed between sessions.