All physicians and nurses are expected to make and present a SOAP note to document the patient’s current condition and their progress. This is helpful for doctors and nurses doing rounds or as a reference for future consultations. SOAP notes need to be organized and concise. While learning how to effectively create a SOAP note is through a clinical experience, this article can give you a heads up on what SOAP notes are and how they are written.
10+ Printable Soap Note Samples
1. Printable Soap Note
2. Soap Note Assessment
3. Professional Soap Notes
4. Soap Note Format
5. Standard Soap Note
6. Clinical Soap Note
7. Editable Soap Note
8. Comprehensive Soap Note
9. Student Soap Note
10. Daily Soap Note
11. Sample Soap Note Format
What is a SOAP Note?
SOAP, in medical terms, is an acronym for Subjective, Objective, Assessment, and Planning. It is a documentation done by physicians and nurses to jot down statements and diagnosis in a patient’s medical chart to obtain specific information about the patient during the consultation session and the information will be used to assess and treat the patient’s problem, which is also recorded in the SOAP note.
To examine the patient, it is divided into four categories:
- Subjective: leaning towards the patient’s behavior,
- Objective: focusing more on the observable and measurable data,
- Assessment: analyzing the information provided by the patient, and
- Planning: outlining the next course of action.
How to Write a SOAP Note
This part is where the physician puts down the information of the client’s direct quotes about his complaints and personal or medical issues that the client is experiencing that affect his daily activities. When writing this part, make sure to write the complete and relevant details of the client’s symptoms based on his statements. Also noted his mood, motivation, and his willingness to participate in this part. If you have encountered previous consultations with the patient, note also the progress he has from the last encounter.
The Objective part should present facts about the client’s diagnosis about his physical or behavioral symptoms, appearance, and his mood. Examples of how to write this part are the client’s verbal and nob verbal communication, body posture, reaction when discussing certain issues, general appearance, behavior, response and participation in the consultation, and mental status. If the client has previous medical records or psychological tests; it can also be included in the Objective part. Since this part is about focusing on the facts presented, don’t put personal judgment, opinions, and assumptions especially without any supporting data for your statements.
The Assessment should mention the progress or regression of the patient based on the information acquired from the previous parts. The physician must use his clinical knowledge and understanding to assess the patient’s condition. The Assessment is tricky if your data is not enough to diagnose the patient so if you’re making the SOAP note, make sure to record the relevant and factual data and observation of the patient. The Assessment will pave the way for how the patient can be treated.
The last part is the Planning stage. This is now where physicians will outline their treatment plan and the next course of action based on the assessment he made. Note the any medical attributes that is crucial for the therapeutic goal of the patient and implement the treatment that you and the patient have both agreed to. Avoid making unrealistic goals to be accomplished by the patient as it will only set you both to failure.
What is an example of a SOAP note?
This is only one example on how a SOAP note is written. The following example presented below is taken from Dr. Kori D. Miller from PositivityPsychology.com:
S: “They don’t appreciate how hard I’m working.”
O: Client did not sit down when he entered. Client is pacing with his hands clenched. Client sat and is fidgeting. Client is crumpling a sheet of paper.
A: Needs ideas for better communicating with their boss; Needs ideas for stress management.
P: Practice conflict resolution scenarios; Practice body scan technique; Go for a walk during lunch every day for one week.
Are SOAP notes still used today?
Yes. SOAP notes are used as communication tool between doctors and nurses to document their patient’s progress. These notes are kept mostly in electronic medical records and these can be used by other doctors to know the patient’s medical history.
Once you’re done making your patient’s SOAP note, proofread it first before putting it in the patient’s official medical record. Make sure to proofread the SOAP note; it should use correct grammar, spelling, and punctuation. Review your choice of words; are they culturally sensitive? Using insensitive terms that describe your patient is a big no-no, so avoid using it. Keep your notes short and straight to the point.
You are recording the diagnosis and assessment of the patient, not make an essay about the patient. And lastly, when quoting a patient, use his exact words and put quotation marks in his statement. Although making a SOAP note is a little ardous since you have to be precise in your notes, the outcome of seeing your patient get better is a great achievement to have. If you need help in making notes relating in the medical field, click on these sample templates and download now!
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