SOAP Note

Oct 20, 2020 | 0 comments

SOAP Note

Oct 20, 2020 | Uncategorized | 0 comments

Basic Information About SOAP Note

Introduction

The Subjective Objective Assessment and Plan (SOAP) note is a method that is widely used by healthcare providers to document patients’ details.

Healthcare workers use the SOAP note to document information in an organized and structured way.

This method was theorized 50 years ago by Larry weed.

It acts as a reminder to clinicians of specific tasks that should be documented and provide a framework for information evaluation.

Structural SOAP notes give practitioners clinical reasoning with their cognitive framework.

Healthcare workers can easily access and treat patients from an established SOAP note through clinical reasoning.

SOAP notes act as a communication document for health professionals.

They also provide information about the patient’s or client’s health status.

The SOAP note structure provides the reader with a documented checklist that acts as a potential index and a cognitive aid to retrieve records for informational learning.

To get a better idea of How to Make SOAP Notes Easy, watch the video tutorial from NCLEX Study Guide.

The video takes a look at each of the four components so you can understand this neat and organized way of note-taking.

Read on for more information.

Function 

SOAP notes have four headings.

They are

  • Subjective
  • Objective
  • Assessment
  • Plan

Below is a description of each heading.

Subjective 

A healthcare provider documents information under this section from the subject’s experience, the patient’s feelings, personal view, or information from a close person to the patient.

If the health provider works with an inpatient, the interim information should be included in this section.

It’s important to highlight this section correctly because it provides a framework for the assessment and the plant section.

Chief Complaints (CC) 

The chief complaint is a report by patients.

A report shows a previous diagnosis, a symptom, condition, or a short statement describing why the patient needs attention today.

The CC can be described as the paper title that allows the reader to sense what the document entails.

Shortness of breath, vomiting, headache, chest pains, hallucination, or decreased appetite are examples of chief complaints.

Patients are encouraged to state all their problems to a physician.

This is because most patients have more than one chief complaint, and their first problem may not be the most significant.

A physician should pay attention to details when describing their problems to discover the most significant one.

Proper identification of the problem is essential for effective and efficient diagnosis.

History of present illness (HPI)

The history of the present illness starts with a simple opening line.

It includes

  • The patient’s age
  • Patients gender
  • Visiting reasons

Example: 20-year-old male presenting with chest pains.

This section is where patients elaborate more on their chief complaints.

For a structural and organized HPI, an acronym OLDCARTS is used.

  • Onset

When the chief complaints began.

  • Location

The location of the chief complaints.

  • Duration

The length of time the CC has been going on.

  • Characterization

How does the patient describe the CC?

  • Alleviating and aggravating factors

What conditions and factors make the CC worse or better?

  • Radiation

Is there a CC movement from one location to another, or does it stay in one location?

  • Temporal factor

Is the CC better or worse under certain conditions or time of the day?

  • Severity

A scale of 1(least) to 10 (worst)is used to determine the severity of the CC.

When writing details, clinicians should focus on the clarity and the quality of the patient’s notes.

Patients history 

  • Family history

Include the applicable family history.

To avoid lengthy details, do not include the medical history of every individual in the family.

  • Social history

Use the acronym HEADSS for this section

You highlight the home and environment, education, employment, eating, activities, drugs, sexuality, suicide, or depression.

  • Medical history

Include relevant current and the past medical condition

  • Surgical history

If the patient has had previous surgery, including the year and the performing surgeon.

Review of Systems (ROS) 

A review of systems is a list of questions that help a clinician discover symptoms not mentioned by the patient.

Musculoskeletal 

  • Joint noises
  • Stiffness
  • Swelling
  • Toe pains
  • A decrease in right shoulder movement.

Gastrointestinal 

  • Heartburn
  • Constipation
  • Dyspepsia
  • Abdominal pain
  • Hematochezia
  • General
  • Weight loss
  • Loss of appetite

Current Allergies and medication 

You can list the current medication and allergies on either the objective or the subjective section.

When documenting the medication, including the name, dose, how often it takes, and route.

For example

Aldactone 500mg orally two times a day for 10days.

Objective 

The objective section highlights the objective data from the physician’s assessment of their patients.

The data documented include

  • Laboratory data
  • Imaging results
  • Physical examination findings
  • Vital signs
  • Review and recognition of other clinicians’ documentation.

It’s essential to distinguish between signs and symptoms when documenting.

Symptoms are the patient’s descriptions and are documented on the subjective heading.

Signs are documented on the objective heading, and they are objective findings by the clinicians relating to the symptoms reported by the patient.

Example

Stomach pains are included in the subjective description, while abdominal tenderness to palpation is highlighted in the objective description.

Assessment 

This section highlights the combination of the subjective and objective evidence to come up with a diagnosis.

The assessment section includes assessing the patient status through problem analysis, the interaction of the problems, and status changes.

The constituents of this section include

 Problem 

A problem is a diagnosis.

Problems are listed in order of importance, with the most significant at the bottom.

Differential diagnosis 

Differential diagnosis is a list of possible diagnoses.

It is listed from the most diagnosis to the list.

It also highlights the thought process behind different possible diagnoses.

The decision-making process is elaborated and explained in-depth in this section.

The possibility of other diagnoses that may be deemed harmful to the patient but are less likely is also included.

Plan 

This section is included when there is a need for further consultation and testing from other clinicians to diagnose the patient’s illnesses.

Any additional steps for patient treatment are also included.

Future physicians use the information to know what to do next.

Every problem listed should

  • Include specialist referrals or consults.
  • State the testing required and the rationale for choosing the test to correct the problem.
  • Include medication or therapy is needed.
  • State patient counseling and education.

Taking into account the subjective and objective information comprehensively in a SOAP note will help you assess the diagnosis correctly to develop a patient-specified assessment and plan.

Looking for a SOAP note template? Download Blank SOAP Note Template, Physical Therapy SOAP Note Template, Pediatric SOAP Note Template, Nursing SOAP Note Template, Newborn SOAP Note Template here

Issues of concern 

Writing a medical note has been an issue of concern and a topic of discussion for a while.

Although the SOAP note order follows the Subjective Objective Assessment and Plan arrangements, it can also rearrange the order.

To provide the most irrelevant information, you can rearrange the order to be APSO (Assessment Plan Subjective and Objective).

This arrangement helps the other clinician to find information and documentation quickly from another colleague’s assessment and plan.

A study showed that the APSO order was better than the SOAP note order.

The comparison was in terms of accuracy, speed, and usability of information for chronic illnesses.

APSO is much better at streamlining communication.

It is not easy to document changes on the SOAP note overtime.

Many clinical situations may be required to do another diagnosis and treatment when the evidence changes over time.

The SOAP model leads to a significant gap because it does not integrate time into its cognitive framework.

SOAP model includes an extension E to act as a reminder of assessing how the plan worked.

Clinical Significance 

When you compare medical notes 50 years ago to now, they have expanded in length and breadth.

The medical documentation is now versatile to serve a variety of needs.

Medical notes are in electronic documentation to accommodate today’s needs.

It is easy to incorporate and accommodate large volumes of data with electronic documentation.

When making the medical record, it is essential to ensure they are accurate for the information to be harmless to the patient.

Using the SOAP note is important because you can quickly locate data.

Effective SOAP Notes Tips 

SOAP notes are an abbreviation of (Subjective Objective Assessment and Plan) notes.

This is a documentation method that is widely used by healthcare providers.

Healthcare providers write SOAP notes on the patients’ charts in an organized way through this method.

Finding the right time to write soap notes

Before writing SOAP notes, take personal notes to assist you when registering.

Avoid taking soap notes when you are in session with a client or a patient.

Do not take too long in writing soap notes after you have ended a session with your client or patient.

Avoid writing statements that do not have supportive facts and figures.

How to write soap notes 

When writing soap notes, ensure they are brief and registered in the past tense.

They should be informative and focused on the patient in question.

Use a professional tone. 

Use a professional voice when writing your soap notes.

For example, instead of writing your client had a blast, you can say the client smiled during a therapy session.

The difference between blast and smiled is that the latter has a formal tone.

Avoid wordy phrases and sentences.

Be Brief and focused to the point when writing your notes.

This way, your sentences can be easily understood by another practitioner.

Do not be biased in your phrases. 

Overly positive and negative phrasing may not have supporting evidence about the client.

Your statements should give information about a client under certain circumstances without making assumptions or judgment.

Write specific and concise statements. 

Instead of writing, the client was able to verbalize her name, say; the client verbalized her name after the clinician asked her.

“Was able to” in the first sentence is unnecessary.

The latter statement provides details under observed circumstances.

The statement is specific and not wordy.

Do not use subjective sentences without evidence.

Some words in a sentence may not help the reader understand the patient’s behavior.

Statements like the patient were very sad does not convey a clear description.

Avoid using words like very, a lot, a little in your notes.

Use statements that will not make the reader make assumptions about the patients’ state.

Clearly describe sentences will enable the reader to have supportive evidence on the condition of the client.

Ensure your pronouns are not confusing 

Confusing pronouns may not bring a clear picture of who is being talked about.

Avoid statements like; the practitioner instructed the client to say her name.

Although this statement may look correct, it is unclear the name the client was supposed to state.

Instead, you can say, the practitioner instructed the client to tell the client’s first name.

Accuracy is key but do not be judgmental.

SOAP notes are mostly written for other healthcare providers. Ensure the notes are not interpreted as offensive when a family member reads it.

 

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