SOAP Note Example and SOAP Note Template

Feb 6, 2022 | 0 comments

Feb 6, 2022 | Writing Guide | 0 comments

What is a SOAP Note

A SOAP note is a communication document that contains information about a patient that can be passed on to other healthcare professionals. The name is an acronym for Subjective, Objective, Assessment, and Plan. Our SOAP note example and SOAP note template below can be used as a guide for recording clinical observations and summarizing care plans, clinical information, and nursing diagnoses.

S-Subjective

The subjective section (S section) of the note includes different information the patient has shared about his symptoms and feelings about his condition. This section may also include information from family members and friends of the patient.  The S section may also include specific information about the medical history of every person, relevant client behaviors, and social circumstances.

  • Example. Client reported _____________ problem, feeling, action, etc.

O-Objective

Objective data includes vital signs and test results that have been recorded by healthcare professionals.

The objective sections (O section) of a SOAP note include the observable or measurable data. It is important to remember that the information in this section is strictly objective and factual, meaning that it does not include the practitioner’s interpretation or opinion. Instead, the data collected here comes from tests or examinations performed by health care professionals. For example, if a patient complains of chest pain and has an elevated heart rate and blood pressure, this information would be included in the O section.

The Objective section is NOT the place for opinions, connections, interpretations, etc.

The O section might begin with an introductory sentence outlining how long the session was.

  • Example. Client participated in ____minute session in _______setting for skilled instruction/intervention in _____________.

Sometimes, the O section then gives an overview statement summarizing observations and client deficits. This is optional.

  • Example. Client presents with ___________ (disease, disability, deficit, etc.).

Next is the most important part of the O section—what happened and what you observed. There are multiple ways to organize an O section.

  1. Chronologically
  2. This might be the easiest way to organize it, especially if you are new to SOAP notes.
  3. Chronological order means you write what happened in the order it happened.
  4. Ex. First the client…..Second, the client…….Next, the client…..
  5. If you organize it chronologically, make sure to include all treatments and relevant observations but remember that you do not have to include every detail of what happened.
  6. Categorically
  7. Categorical means organizing the O section according to categories of things that you and the client did or that you observed.
  8. Example. Category/Deficit #1
  9. Example 1
  10. Example 2
  11. Category #2
  12. Example 3
  13. Example 4
  14. If you organize it categorically, sometimes it is helpful to group things into broad categories because there may be overlap between one section and another.
  15. Evaluation Findings
  16. If the session was an evaluation, the SOAP note may look a little different
  17. An evaluation SOAP note must include all scores from the eval. This could include:
  18. Summary of Screening results
  19. Assessment/Test/Evaluation results
  20. Pictures
  21. Observations during evaluation
  22. Evaluation scores can be listed in bullet points or in paragraph form.
  23. Ex. Name of Assessment
  24. Category: Result
  25. Observations
  26. Sometimes it makes sense to incorporate observations throughout, but some people find it helpful to create a section in their O-section for observations

A-Assessment

The assessment section of the note contains a diagnosis based on the data gathered in the previous sections. It may also contain progress notes regarding the prognosis of the patient’s condition.

This section is also where the provider creates a list of possible diagnoses or problems based on subjective and objective data. The assessment section may also include a statement of what is causing the problem or condition (etiology), what are the risk factors for developing this condition, and what are its implications for future health.

The A section is where you make sense of what you wrote in the O section and S section.

Many A section includes 3 P’s plus needs:

  1. Problem or Cause-Effect statements
  2. These statements provide an interpretation and explanations of the patient’s problems, of evaluation findings, and of observations.
  3. A statement of progress (progress notes)
  4. Sometimes we can compare the scores or observations from our O section to what we have seen in the past week.
  5. This is important because someone reading your SOAP note now understands whether your O section shows the patient is making progress or not
  6. A statement of potential
  7. While it is easy to focus on the problems and issues, we also want to highlight things in the previous section that indicate the potential this client has.
  8. This could include the client’s strengths, their support system, their attitude, etc.
  9. A summary statement of needs
  10. This is often a justification for services or a justification for discharge.

Example:

Problems: ______________(condition/deficit) causes client difficulty with ________________ (occupation).

Potential: Client shows rehab potential to make progress as indicated by ______________ (supports/client factors/ etc.).

Progress: Client demonstrated progress in _________ (during session or throughout therapy).

Justification of services: Client would benefit from skilled intervention/instruction focused on __________________________ (tasks/strategies for specific occupations).

P-Plan

The plan section outlines any further testing or treatment that is needed for the patient’s condition.

This is where the provider states what will be done to manage the condition or problem identified in the assessment section. The plan may include specific treatments, medications, referrals to other providers for further testing or treatment, instructions for home care, etc.

The P section includes any treatment recommendations or referrals to specialists or other types of care providers required by the patient’s condition or symptoms. This section might also include relevant lifestyle changes to be considered by the client.

Example:

Continue tx ___min #x/wk for # wks to work on ____________ (intervention) for _____ (goal/occupations).

Referral to___________ recommended to address_______________.

Family provided with resources including _______________________.

Purpose of SOAP Notes

  1. The proper purpose of the soap note is to facilitate care for the patient. It contains the client’s medical record and also shows the health status of the patient.
  2. The soap note provides a place to track medical issues in one location, with all members of the healthcare team. or when services of others are needed, tracking of issues becomes easier.
  3. It also helps to facilitate communication by providing an easy way for healthcare providers (HCPs) to quickly get a picture of what is going on with the patient. Use language common to all health practitioners
  4. The soap note also allows HCPs to more easily share information about a patient when referring them to specialists or when multiple HCPs are involved in their care.
  5. It can be used as evidence in case law if needed, but should always be written so that it only focuses on objective findings and evidence-based treatment plans. The subjective portion of the note should focus on what you see, hear, feel and smell while at the bedside.

SOAP notes Abbreviations

Some commonly used abbreviations for SOAP notes are:

b/c- because

CC- chief complaint

c/o- complained of

cl- client

d/t- due to

Dx- diagnostic test

Ed- education

e.g.- exempli gratia, use when giving an example

HPI- history of present illness

i.e.- id est, use when giving alternative explanation or wording

min, mod, max- minimum, moderate, maximum

Mx- monitoring test

Rx- treatments

sx- symptoms

w/, w/o- with, without

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