A SOAP note is a medical document used to present a patient’s information. During ward rounds, medical personnel and students need to take notes about patients. This information has to follow a specific format to make it easily understood by all members of the medical team. The information is used for patient care.
The note includes a particular order and components. It is used to record the patient’s history, admission notes, and other relevant confirmation in the patient’s chart. The main aim of this document is to have a standard way of presenting patients information in the patient’s chart to avoid confusion among the members of the medical team.
New medical students and other members of the medical team may have difficulties writing the SOAP note. To get a better understanding of what to include in the note, it’s essential to consider samples.
What does SOAP stand for?
SOAP is an abbreviation for:
- S: Subjective
- O: Objective
- A: Assessment
- P: Plans
Let’s get more in-depth and look at the details of what the terms mean.
This is information emanating from the patient and is usually in the form of a story—it’s what the patient feels and their view of the problem.
After listening to the patient’s story, the health care officer will highlight areas of concern to determine the patient’s case. This is an objective assessment of the patient’s problem.
The health officer collates the patient’s concerns and includes an expert opinion of the therapists regarding both subjective and objective reports.
After a professional analysis of the patient’s concerns, the health care provider will develop a workable plan to achieve set objectives and treatment.
The history of SOAP notes
Preparation of SOAPs started in the 1960s. Dr. Lawrence Weed is credited with the development of SOAPs; he was a faculty member of the University of Vermont.
The main aim of SOAPs was to assist in problem-oriented medical records. I bet you must be asking, what’s the purpose of SOAPs in today’s era?
Every medical facility must have a standardized way of presenting a patient’s information. They must have templates or SOAP examples to assist their staffs in organizing patients data in a way that every healthcare personnel will understand.
If a medical institution has no specified way of organizing patient’s information, it’ll be very difficult for members of the medical team to read from the same page. Different formats for presenting patient’s information in the patient chart will lead to confusion. From this explanation, you can see that there are many advantages and disadvantages of SOAP notes.
Pros and cons of SOAP notes
As you have already seen, SOAP presents a uniform way of recording and presenting the patient’s information. The SOAP assists healthcare providers to arrive at the patient’s problems and develop a workable way of solving the identified problems.
The healthcare providers will use the format to know what ails the patient and in turn, institute the best medical plan to treat the patient.
Besides, the healthcare providers use medical terms that everyone in the team understands to present patient’s information. Thus we can say that SOAPs assist in presenting patient’s information concisely and clearly.
SOAP notes utilize many abbreviations and acronyms that are only known to those in the medical field; thus, ordinary people may not understand the information in SOAP notes.
The information in SOAP notes is inadequate for physiotherapists since they lack information on how they’ll take care of the outcomes or functional goals.
Having this background, we can now proceed and see how to write SOAP notes. In essence, it’s just a simple medical document with four components.
How to write a SOAP note (a step by step guide)
It essential to note documentation is a critical part of the delivery of healthcare services. Though documentation is very crucial in healthcare settings, most healthcare personnel ignore this fact and end up using unspecific ways of recording patient’s information. In most cases, the description is very shallow, and fellow members of the medical team may not comprehend.
Though we don’t have a specific guideline on the details or the length of the patient’s data, one must provide sufficient information that will assist in giving the best care to the patient. Below is a guide by the American Physical Therapy Association on the patient information that should be recorded;
- The intervention to be given
- Patients self-report
- The equipment to use
- Patients response
- Negative outcomes/ complications
- What led to changes in intervention
- If goals and set objective were achieved
- Communication with, e.g., the patient’s family and other members of the healthcare team
Any healthcare provider must understand that other healthcare providers will use the information they record in SOAP notes either at the same item or in the future. It’s thus essential to make sure that what they record is legible and can be comprehended by others.
We had earlier given a brief definition of the components of a SOAP note. Let’s get the details.
Writing the subjective
The patient’s highlights their plight in the form of a story. They will give details on their history, functions, signs and symptoms, and any disability. The information gathered at this stage is detailed and comes not only from the patient but also form the family members or other members of the healthcare team.
When taking the notes, the writer must include direct phrases to capture the exact words of the patient. The number one goal of this section is to allow the patient to share their side of the story in how they view their problem in terms of rehabilitation progress, quality of life, and functional performance.
These are some of the significant details that you may find in a subjective part of a SOAP note:
- C. initials for the chief complaint
- Patient’s history
- A description of the pain
- Etiology MOI (Mechanism of injury)
- It’s essential to note that this is the most critical part of the SOAP since it’ll assist in the objective component as you evaluate the real potential injury.
- In this section, you must make sure you neglect any query that ends with a No or Yes answer.
- Only record information that is relevant to patient care
- Avoid pre-judging the patient. For example, thinking the patient’s is exaggerating the case.
Writing the Objective part
In this section, you’ll include your observations as a health care provider. The information to include in this section should be quantifiable. For example, you should record all the relevant interventions such as the frequency, duration, and equipment used. As a health officer, you need to record the patient’s response to the interventions. Remember to include their communication with other health care providers and family members.
These are some of the things that must be in the objective part:
- ROM (Range of motion)
- Special tests
- Palpation (soft and bony)
- Manual muscular tests
What to note in this section
- Offer adequate information
- Record all special tests in his section
- Don’t use general interventions like ROM, go for more specific ones such as Resistive range of motion, active and passive
- Identify the possible injury in this section to figure out the main problem
The assessment section is another very significant part of the SOAP note since it’ll contain the expert opinion of the healthcare provider concerning both the subjective and objective findings.
In this section, you must offer a detailed explanation of why you opted for a specific intervention. You should also offer the patients progress to the set goal and objectives. Any changes that need to be implemented to any intervention must also be recorded in this section. Remember also to include any positive or negative response the patient may have to the interventions.
- Avoid general statements that seem vague. For example, the patient is doing well.
- For every record, you must offer sufficient details
Writing the plan
The plan is the final part of the SOAP note, and it includes the relevant interventions for the patient’s case. It includes the specific treatments that will be implemented on the patient, such as medication, therapies, and surgery.
This part must include both short and long term interventions. For example, you can include a change in lifestyle as a long-term goal.
The section should also include expected outcomes from the treatments; include aspects like ROM, reduced pain, and increased strength.
What to note:
- Make sure the plan is conclusive
- Avoid vague descriptions
- The plan should be considered as a daily guide that should be followed until the set objectives are achieved.
How to write SOAP minutes
Once you’re through with the SOAP, it now opportunity to put the notes together to come up with the minutes. Consider these tips as you do write:
- Consider writing the minutes immediately, you’re through with the SOAP i.e., when the details are still fresh in your mind.
- Review the outline, and if necessary, you may add more information or clarify points. Additionally make sure all the motions, decisions, and actions are clear.
- Provide sufficient information. If a motion was preceded by a discussion, you must highlight the main point supporting or opposing the decision. In the case of the Board of Directors minutes, it’s recommended to briefly describe actions are taken and how they were arrived at.
- Edit to ensure the minutes are concise and clear
Consider the following for the format
- Be objective
- Use the same tense in the entire copy
- Record motions and seconds without mentioning names
- Record fast not personal observations
- When referring to other documents, avoid summarizing them. You should attach an appendix or highlight where they’ll be found.
Tips when taking SOAP notes
Design an outline
Creating an outline/template makes it easy to writes and decisions under each specific item. For handwritten notes leave spaces below each item to fill in the details.
Check-off attendees as they come
If you know the members check them off as they enter the meeting room. If not possible, each must introduce themselves as the meeting starts or else circulate the attendance list to all members.
Record decisions immediately
Decisions on action items must be recorded immediately to make sure they are accurate.
Ask for clarification
If no decision is made on a certain item, you should ask the members to clarify or reach a decision.
Record only the relevant information
You can’t capture all that was discussed in the meeting. Record the main points, decisions, and actions.
Record the meeting if possible
If you can’t keep up with the pace of taking notes as people talk, you can opt to record the conversation in your iPad, Smart Phone, or any other recording device. Make sure the participants are aware you’re recording them. The recording can be of great value when you need clarification.
Sample SOAP Note
Consider this as an example of a SOAP note
Chief complaint: 32-year –old female presents w/ a chief complaint of: “my upper right jaw has been paining for the last one week.”
History of present illness: Pt. relates the history of pain and swelling in the last one week, previously asymptomatic.
Med Conditions: Pneumonia
Past Sx: Ear lac 2017
Social Hx: Alcohol +
Vital: BP 124/80
Extraoral: (Asymmetry, pain, swelling, erythema, parathesia, TMJ)
No asymmetry, no swelling, the patient points to exactly #18(FDI#39) for pain extraorally.
Intraoral: (Swelling, Erythema, Exudate, Hemorrhage, Occlusion, Mobility, Pain, Biotype, Hard Tissues)
#17(FDI #29) Infra erupted, occlusion on pericoronal tissue of #19.4 #19. Fully erupted, no hemorrhage, fetid odor, erythematous gingival tissues, slight exudate, and pain to palpation pericoronal tissue #19.
#19 infraerupted & occluding on opposing gingiva
# 19 periconitis
Plan: (timing of extractions and periconitis can be contentious, e.g., extraction#17 today and or operculectomy #19.
Antibiotics × 7 days (Amox/Pen)
Extraction # 19-
Motrin 500mg Q 4-6h × 7 days
Tylenol 250mg Q 4-6h × 7 days
Percocet T2 prn pain (no driving)
Follow up (pm)
Treatment Provided Today: Consent signed
34mg Lidocaine+ 0.017 mg epi, Rx’d antibiotics, CHX 0.12% TID× 10days ,Operculectomy #17, reappointment for exo#19, under local anaesthetic. Post-surgical instructions.
Having read this guide, you’re now good to go.