How should progress toward goals be documented in the SOAP note?

In a SOAP note, progress toward goals is documented under the Assessment section. This is because the Assessment part is designed for the clinician to evaluate the patient's condition, including any changes in their status in relation to the goals set in previous sessions. Here, the clinician assesses how well the patient is meeting their goals, any improvements made, setbacks experienced, and the overall effectiveness of the treatment plan.

Documenting progress in this section allows for a consolidated view of the patient's progress over time, connecting it to the treatment being provided. It is essential for tracking the efficacy of interventions and planning future treatments.

In contrast, the other sections serve different purposes: the Subjective section captures the patient's self-reported symptoms and feelings; the Objective section includes measurable data such as vital signs or physical exam results; and the Plan outlines the expected interventions or treatment adjustments. Each of these sections plays a distinct role, but the Assessment is specifically oriented towards evaluating the outcomes related to the patient's goals.