SOAP notes you dictate, not type
The session ends and the objective section is already written from what you tapped. Say or type the rest in the room, then sign. Nothing follows you home.
How a note gets written
- 1
S is your words
Dictate, or type quietly when the client is in the room. Either way it lands in the Subjective field exactly as you said it, nothing rewritten.
- 2
O is your taps
The trials you tapped during the session are already written up: 16/20 (80%) at word level with minimal verbal cues. Cued and independent counted separately.
- 3
A and P are two short lines
Your assessment and plan, in your voice. The numbers are already on the screen, so this is the only part you write from scratch.
- 4
Sign
Signing locks the note. Anything edited afterwards is kept as a version, so the record you signed is the record that stays.
What is in the box
- Dictate into any field, or type: voice is a shortcut, never a requirement
- Objective section pre-filled from the session's trials, with cue levels
- Seed today's note from the last signed note when the plan has not changed
- Last session's numbers sit next to every goal while you write
- Signed notes lock, with every later edit kept as a version
- Dictation runs under a signed BAA, so audio is handled like the rest of your PHI
Ten notes a night, five minutes each. That is most of an hour, every evening, unpaid. Vochella gives it back.
Less than the price of one private session a month.