I was having a conversation with a consulting client the other day about this topic, and I realized how passionate I am about it, and maybe how misunderstood this section of the progress note can be.
    That is, the Subjective Material in a progress note.

    This is one of those topics where my bias may be a play, and I acknowledge that up front.  

    Those of you who have worked with me before as your documentation consultant, you have heard how I think about progress notes in SOAP – Subjective, Objective, Assessment, and Plan.  Most of us who have practiced a while were trained this way.  And SOAP Notes, or some version of it, is still a pretty common way to document.

    When I read progress notes, though, I find that there can be a misconception of what the Subjective material in the note is meant to represent.
    So, I thought I’d share a few words on the topic.

     
    Let me start with a definition of the word “subjective”.  I used my trusty Google search engine and found –

    Adjective. Something that is subjective is based on personal opinions and feelings rather than on facts.  We know that taste in art is a subjective matter.  (Collins Dictionary)

    Another definition says –

    Influenced by, or based on personal beliefs or feelings, rather than on facts:  Whether something is objectionable is a subjective matter. (Cambridge Dictionary)
     
    While Objective material in your progress notes should be focused on FACTS, subjective material is, as Britannica says, “relating to the way a person experiences things in his or her own mind”.
     
    In terms of progress notes, the subjective material is largely the material the client brings into the room from their lives.  It’s rich, experience-filled, but it is material that is “based on personal beliefs or feelings” and not based objective, observable facts.  So, it’s important, but we want to make sure that its documented in context of the lens of the client.

    Of course, the only way we know what’s occurring in the life of our client outside of therapy is by the report of the client – or in some cases – from family or significant other people (which is also subjective material).  How the client is doing in the world, how they are implementing the skills or perspectives they are gaining from therapy is an important part of documenting, so you really want to capture that.

    But, of course, you don’t want to capture all of it, right?  At some point, we come to the border where we cross over from progress to process note.  Which we also don’t want to do.

    The good news is that the details of the event are, in most cases, less important to gather than the client’s response.  We can gather some basics of the story and capture how they responded and what skills they used or were not able to use.

    So, what makes it a good idea to capture it?

    There are a lot of different answers to that question.  We certainly want to have a running understanding of how our work is generalizing into the client’s life and capturing that in subjective material is a helpful way to do that.  It also can help us keep track of how the client is utilizing the skills that we’re working on.

    But it’s also helpful in documenting continued reporting from the client of current symptoms and deficits that is in context of their real-life experiences.  Which is a helpful way of documenting the progress the client is making as well as a basis of the symptoms and deficits that still exist.

    Which is all about the trajectory of treatment.