NDIS SOAP Notes Guide for Support Workers

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Why Are SOAP Notes Important?

SOAP notes serve several critical purposes:

• Consistency: Ensures all professionals document information in a unified format.
  
• Clarity: Clearly separates the client’s input from professional observations and interventions.
  
• Continuity of Care: Makes it easier for other clinicians to follow treatment progress.
  
• Legal and Compliance Records: Provides clear evidence of services delivered and rationale for clinical decisions.
  
• Funding Support: For NDIS providers, well-documented SOAP notes can help substantiate funding claims and compliance.
  
  

Detailed Breakdown of SOAP Components

1. Subjective (S)

This section includes information reported directly by the client, caregiver, or family. It reflects their perceptions, feelings, and experiences.

What to Include:

• Chief complaint (e.g., "I’ve been feeling very tired lately.")
  
• Pain levels or emotional status (e.g., anxiety, depression, confusion)
  
• Changes in appetite, sleep, or daily function
  
• Client concerns about medication or therapy
  
• Relevant social or environmental updates (e.g., changes at home)
  

Example:

"Client reports experiencing increased fatigue over the last 3 days and difficulty completing household tasks."
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2. Objective (O)

This section presents measurable or observable data gathered by the clinician during the session.

What to Include:

• Vital signs (e.g., temperature, pulse, blood pressure)
  
• Physical observations (e.g., gait, muscle strength, posture)
  
• Behavioral observations (e.g., withdrawn, agitated)
  
• Test results or assessment scores
  
• Functional performance (e.g., time to complete a task)
  

Example:

"Client was observed taking frequent rests while walking. Blood pressure measured at 135/88. Scored 22/30 on the cognitive recall test."
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3. Assessment (A)

This is the clinician’s interpretation of the situation, combining the subjective and objective data. It reflects professional reasoning and judgment.

What to Include:

• Diagnosis or problem summary
  
• Changes since last visit
  
• Progress toward goals
  
• Justification for continuing or changing treatment
  

Example:

"Client's fatigue appears to be increasing, impacting daily function. Mild improvement noted in memory recall. Progress is moderate but consistent with plan goals."
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4. Plan (P)

This section outlines next steps based on the assessment. It should be specific, actionable, and trackable.

What to Include:

• Therapeutic interventions
  
• Medication or treatment changes
• Client education
• Next session focus
  

Example:

"Continue strength training exercises. Introduce energy conservation techniques. Monitor fatigue levels. Follow-up next session to evaluate coping strategies."
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Best Practices for Writing SOAP Notes

Writing clear SOAP notes is one of the most important responsibilities of an NDIS support worker. Here are simple ways to make your notes accurate, compliant, and useful for the whole care team:

• Write notes immediately after the shift: Memories fade quickly. Writing notes while the details are fresh ensures accuracy and prevents missing important information.
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• Keep sentences short and clear: Use simple language and avoid long, confusing explanations. Short sentences are easier for coordinators, families, and auditors to understand.
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• Stick to facts, not opinions: Document what you saw, heard, or measured - not personal interpretations or emotional reactions.
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• Be specific and measurable: Precise details improve clarity. Instead of “Participant walked well,” try: “Participant walked 20 metres with a four-wheel walker and one verbal prompt.”
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• Avoid jargon or clinical language: Use everyday terms unless it’s part of the participant’s plan or behaviour support requirements.
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• Maintain privacy and confidentiality: Don’t record unnecessary personal information. Only write what is relevant to the care delivered.

Do & Don’t Examples

Do:

1. “Participant required verbal prompts to finish breakfast.”
2. “Participant appeared tired and needed additional time for grooming tasks.”
3. “Participant declined community access today and requested quiet time.”

Don’t:‍

1. “Participant was lazy today.”
2. “Participant was being difficult.”
3. “Participant acted weird.”
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Common Mistakes to Avoid

Writing SOAP notes may seem straightforward, but small mistakes can make notes unclear, non-compliant, or even risky. Here are some common pitfalls to watch out for:

• Writing emotionally charged words - Avoid subjective labels such as “rude,” “lazy,” or “angry.” Stick to neutral, factual language to maintain professionalism.
• Using vague descriptions - Phrases like “did well” or “struggled a bit” don’t give enough information. Be specific about what the participant did or needed help with.
• Omitting follow-up actions - Always document what needs to happen next, whether it’s monitoring, reporting to a coordinator, or adjusting the support plan.
• Copy-pasting old notes - Each shift is unique. Reusing previous notes can lead to inaccurate records and non-compliance.
• Writing overly long or unclear entries - Keep notes concise, structured, and easy to read. Avoid unnecessary details that don’t relate to support delivery.
• Failing to observe privacy and confidentiality - Including unrelated personal information can breach privacy rules and NDIS standards.

Tip: Review your notes after writing to ensure they are clear, accurate, and actionable.
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How Imploy Helps Support Workers With SOAP Notes?

Writing good notes can be challenging, especially when you’re busy on shift. Imploy makes SOAP documentation simple, compliant, and fast.

Here’s how Imploy helps:

• Pre-built SOAP templates built specifically for NDIS support workers.
  
• Mobile-friendly note-taking, so workers can write immediately after sessions.
  
• Smart prompts and guidance to eliminate errors and reduce risk.
  
• Automatic linking to shifts, participants, and support items.
  
• Real-time visibility for team leaders and coordinators.
  
• Secure cloud storage for audit-ready documentation.
  
• Integrated incident reporting for quick escalation.‍
• Accurate billing, as notes sync with timesheets and invoicing.