How to Complete a SOAP NOTE

What is are SOAP NOTES?

These are typically brief notes written to communicate and document the patient’s current status and plan of care, as opposed to comprehensive histories and physical examinations performed at the time of hospital admission. They are not intended to convey all information about the patient; rather, they are intended to convey pertinent information in a concise manner. This note style is slightly different from what you will be expected to do during your senior OSCE and Step 2 CS, but is more akin to what you will do during clerkships.

SOAP Notes are a ground-breaking, standardized method of medical professional documentation. If you work in a healthcare setting, you are probably aware of the critical nature of detailed and organized medical records documentation. However, there was no standardized format for many years; this prompted physician Lawrence Weed to develop a standard method in the 1960s to assist himself, his fellow physicians, dentists, nurses, and interns in simplifying treatment plans.

It provides a cognitive framework within which clinical reasoning can occur. As we are all aware, healthcare professionals must deal with multiple complex issues concurrently; thus, the new SOAP protocol revolutionized the way client data is organized in a single format that any provider can easily decipher.

What are SOAP (Standard Operating Procedure) notes?

The first question that usually arises is about the acronym SOAP; in SOAP notes, what does SOAP stand for? Subjective, Objective, Assessment, and Plan are the appropriate responses.

The SOAP note template’s standardized format directs practitioners through the process of assessing, diagnosing, and treating a client based on the information contained in each of the note’s sections.

Who makes use of SOAP Notes?

Basically, anyone involved in healthcare could benefit from it. From medical doctors to dentists, psychologists, nurses, emergency medical technicians, and veterinary practitioners, there is something for everyone.

Numerous young healthcare professionals frequently inquire about how SOAP notes are documented. or, more precisely, what information should be included in each section of a SOAP note?

You will become acquainted with this below!

How should Clinical SOAP Notes be written?

You might want to take a look at this Clinical SOAP Note Format Template before diving into the details below!

S stands for subjective.

This is the SOAP format’s first heading. The documentation for this category comes from a patient’s or someone close to them’s “subjective” experiences, personal views, or feelings. Interim information is included in the inpatient setting. This section serves as a backdrop to the Assessment and Plan.

This section is used by health care providers to document a client’s subjective reporting of a concern. It is best to use the patient’s own words or the words of a close relative (like their parent or spouse). To clarify, the following should be reported:

“Patient reports: “I slept poorly last night and have been irritable all day.” We discussed his sleeping patterns and current stressors as potential contributors to his sleep deprivation”.

“Patient reports recent bouts of depression and crying spells and states, “I just start crying out of nowhere.” I have no idea where it is coming from”. I recall Jon mentioning the anniversary of his mother’s death during last week’s session; we discussed this as a possible trigger for his current emotional state”.

The patient reports the Chief Complaint (CC) or presenting problem. This may be a symptom, a condition, a previous diagnosis, or another brief statement describing the patient’s current presentation. The CC is similar to the title of a paper in that it informs the reader of what the remainder of the document will contain. For instance, it could be chest pain, shortness of breath, or decreased appetite.

However, a patient may have multiple CCs, and their initial complaint may be insignificant. Thus, physicians should encourage patients to express all of their concerns, while paying close attention to detail in order to identify the most compelling issue. To perform an effective and efficient diagnosis, it is necessary to first identify the primary problem.

Medical professionals should include a history of current illness (HPI) in this section. The HPI begins with a straightforward one-line introduction that includes the patient’s age, gender, and reason for the visit. For instance: The patient is a 47-year-old female who presents with abdominal pain.

This is the section in which the patient can provide additional information about their primary complaint. The acronym “OLDCARTS” is frequently used to organize the HPI:

When did the CC commence?

The location of the CC is unknown.

How long has the CC lasted?

How does the patient describe the CC?

What makes the CC better in terms of mitigating and aggravating factors? Worse?

Radiation: Is the CC mobile or does it remain stationary?

Temporal factor: Is the CC more severe (or less severe) at a particular time of day?

How does the patient rate the CC’s severity on a scale of 1 to 10, with 1 being the least severe and 10 being the most severe?

It is critical for clinicians to prioritize the quality and clarity of their patients’ notes over the quantity of detail included.

A critical component of clinical reasoning is incorporating the patient’s medical, surgical, family, and social history into your SOAP framework. Medical history is primarily concerned with current or previous conditions; surgical history is primarily concerned with the date and details of any surgery performed; and family history is concerned with familial diseases. However, avoid documenting the medical history of every member of the patient’s family. In terms of social history, the acronym HEADSS may be used, which stands for Home and Environment; Education, Employment, and Eating; Activities; Drugs; Sexuality; and Suicide/Depression.

Finally, it is mandatory to conduct a System Review (ROS).

This is a system-based list of questions designed to elicit information about symptoms not previously mentioned by the patient.

Weight loss and decreased appetite in general

Abdominal pain, hematochezia

Musculoskeletal: Toe pain, decreased range of motion in the right shoulder

Current medications and allergies should be included in the Subjective or Objective sections. However, it is critical that any medication is documented, including the medication’s name, dose, route of administration, and frequency of administration.

For instance, 600 mg Motrin orally every 4 to 6 hours for 5 days.

Objectif

Thus, what is the purpose of a SOAP note? It is quantifiable, observable, and quantifiable data.

This section of the SOAP framework is concerned with the objective data collected during the patient encounter. This may include observations of client behaviors, treatment methods used, client responses to those methods, and any measurable outcomes during treatment.

Vital signs, physical examination findings, laboratory and imaging test results, diagnostic test data, any review of other clinicians’ documentation, patient ability to participate, responses, strengths, mental status, and nature of therapeutic relationship are all examples.

“Patient is awake: aware of time and place, and he is actively participating in today’s session, as evidenced by positive responses and prompt responses.”

 

“Patient has a predominantly flat/blunted affect and poor hygiene. He responds within a few seconds to questions I pose during the session”.

A frequent blunder is failing to distinguish between symptoms and signs. Symptoms are the patient’s subjective description and should be documented under the subjective heading, whereas a sign is an objective finding associated with the patient’s associated symptom. As an illustration, consider a patient who reports having “stomach pain,” which is a subjective symptom. In contrast to “abdominal tenderness to palpation,” a documented objective sign under the objective heading.

Avoid generalizations without supporting data, labels, assumptive statements, personal judgments, and words/phrases with negative connotations and/or are open to subjective interpretation (ex: uncooperative, obnoxious, normal, drunk, spoiled).

A: Evaluation

You may be wondering what goes into the assessment section of the SOAP note. “Assessment” in the SOAP format connects the dots between “subjective” and “objective” evidence in order to arrive at a diagnosis. This is the process of determining the patient’s status by analyzing the problem, considering possible interactions between the problems, and monitoring changes in the status of the problems.

Any changes to the client’s diagnosis or treatment plan can be recorded in this section. This section of the SOAP framework can be used to compare the most recent appointment to previous ones and to identify any additional areas for improvement.

List the problems in ascending order of importance. A diagnosis is frequently used to refer to a problem.

Differential Diagnosis: This is a list of possible diagnoses in order of likelihood, as well as the thought process that led to this list. This section details the decision-making process in detail. Other diagnoses that could be harmful to the patient but are less likely to occur should be considered.

For instance, consider the following: Problem 1, Differential Diagnoses, Discussion, and Solution to Problem 1. (described in the plan below). Rep for additional difficulties.

Repetition of previous statements in the S. O. sections is discouraged. This section should be a problem-oriented medical record that focuses on the client’s progress, regression, or plateau.

P: Prepare

To conclude the note, this section of the SOAP format is used to summarize the patient’s treatment plan. The term “plan” refers to the patient’s immediate next steps and how those steps will advance the patient toward anticipated goals. This is where, based on the assessment section, the next steps can be adjusted as necessary.

This section discusses the patient’s illnesses and the need for additional testing and consultation with other clinicians. Additionally, it covers any additional steps taken to treat the patient. It assists future physicians in determining the next steps to take.

For each issue:

Indicate which tests are required and the rationale for selecting each one to resolve diagnostic ambiguities; ideally, indicate the next step that would be taken if the result was positive or negative.

Take note of the client’s nutritional, physical, and medical characteristics (medications) that will aid in achieving the client’s therapeutic goals.

Referrals or consultations with specialists.

Counseling and education of patients.

Take note of any progression/regression the client has experienced during treatment.

Example:

“The patient will meet with a licensed nutritionist to develop a healthy eating and lifestyle plan.”

“Patient will enroll in yoga classes at a nearby gym.”

“Patient is committed to attending eating disorder group therapy sessions.”

Avoid setting unrealistic, immeasurable goals for the client’s next session.

There are several fallacies that are frequently committed when writing SOAP notes; for more information, see this article about four common errors to avoid when writing SOAP notes.

SOAP’s Clinical Importance

Medical documentation now serves a variety of purposes, and as a result, medical notes have grown in length and breadth over the last fifty years. To meet these needs, medical notes have evolved into electronic documentation. However, an unintended consequence of electronic documentation is the ease with which large amounts of data can be incorporated. These data-heavy notes run the risk of becoming a burden for a busy clinician if the data are not useful. Additionally, if the information is inaccurate, the patient may suffer harm.

Therefore, are SOAP notes still in use? Definitely! It is critical to make the most clinically relevant data in the medical record more accessible and accessible immediately. The advantage of a SOAP note is that it organizes this information in a way that makes it easily accessible. The more succinct yet comprehensive a SOAP note is, the easier it is to follow for clinicians. A significant advantage of the SOAP note is its conciseness. Each section is clearly labeled, and each section is concise and straightforward. Another provider can easily determine where you are in treatment at a glance—and it’s beneficial to remind yourself as well.

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