Session Notes (SOAP) — Quick Refresher
Deadlines, what goes in each SOAP section, and the most common documentation gaps.
Deadlines & Payment
Session notes are due within 48 hours of your session. Notes not completed within 30 days may result in withheld payment. All notes must be signed and submitted before your biweekly payment is released. Most providers find documentation takes about 10–15 minutes per session.
Where to Submit
All session notes are submitted directly in CoralPro. See the step-by-step walkthrough: How to Add Session Notes.
What Goes in Each Section
S — Subjective: Parent/caregiver report — what the family shared about the week, changes at home or school, the child's mood coming into the session.
O — Objective: What you observed and worked on — specific activities and how the child performed. This is where assist levels, repetitions/trials, and duration go.
A — Assessment: Your clinical interpretation — progress toward goals, what's working, what you're adjusting. At 6-month Care Plan reviews, your progress note goes here.
P — Plan: What's planned for next session, plus care coordination, parent training, or follow-up.
The Most Common Documentation Gap
The most frequent issue in documentation reviews: missing assist levels and repetitions. If you facilitated, cued, modeled, or repeated an activity, it needs to be in the note — this demonstrates skilled intervention and supports medical necessity.
Instead of "Patient practiced stair climbing," write "Patient ascended 4 stairs × 6 trials with mod assist at trunk for weight shift."
Questions? Reach the clinical team at clinicalteam@joincoralcare.com or drop into Clinical Office Hours (Wednesdays 6:15–7:15 PM EST /