The SOAP note was first introduced into the medical field by Dr. Lawrence Weed in the early 1970s and was referred to as the Problem-Oriented Medical Record (POMR). At the time, there was no standardized process for medical documentation. SOAP notes provide the physician’s structure and a way for them to easily communicate with each other, which is still helping transform the industry.
How to compose an excellent SOAP note is rather easy if you follow these correct steps. First, you have to understand what a SOAP Note is and why it is used. Generally speaking, a SOAP note is a short form organizing a patient’s personal and medical information and they are used primarily for admissions, medical history, and a few other documents in a patient’s chart.
There are generally four parts to this note. If you follow these steps below you will have created an excellent and to the point SOAP Note that is easy to understand and review.
Subjective: It describes the patients’ current condition and why they came to visit. In addition, it includes a brief synapse of the following: Encounter of injury, how long it has continued since the encounter, essence of pain (how it feels and how sever the pain is), any additional evidence, and any other therapy or treatments the client has received already.
Basically, the documentation’s subjective section should include how the patient is feeling and how they have been since their last checkup in their own words.
As part of the assessment, you may ask the patient:
- “How is your nausea?”
- “How are you today?”
- “How have you been since your last checkup?”
If the patient mentions several symptoms, you must explore each of them, having the patient describe each of the symptoms in their own words.
Objective: This area shows the patients status and facts ie: vital signs, examination results, lab results, patients measurements and age.
This section should include your objective observations of the patient. For example:
- Appearance: you can document that the patient appeared to be very pale and, in much discomfort,
- Vital signs: Document the patient’s vital signs, i.e., the pulse rate, temperature, blood pressure, etc.
- Fluid balance: You can also document the patient’s fluid intake and output in the documentation, including oral fluids, vomiting, drain output, intravenous fluids, etc.
Assessment: A brief statement of medical diagnose for a patients medical visit on the same day the SOAP Note is written. The assessment section is where you have to document your thoughts on the special issues and the differential diagnosis, which will be based on the information you have garnered in the previous two sections. For example, you may note, “Increasing shortness of breath,” “Raised white cell count,” etc.
Plan: This area shows what is going to happen from this point forward with a patient;,ie medications prescribed, labs ordered, referrals..etc..
The plan is usually the final section of the documentation, which is where one documents how they will address or investigate any issues raised during the assessment.
The items you may include in your plan may include:
- Treatments (e.g., intravenous fluids, medication, nutrition, etc.)
- Further investigation (e.g., imaging, lab test, etc.)
- Referrals to specific specialties
- Planned discharge date
- Review date/time
- Frequency of observation and monitoring of fluid balance
SOAP Note Examples & Format
In conclusion, a SOAP Notes are short documents that shows current, past and continuous regimen of a patient. These notes will stay within a patients’ medical history for future reference. Moreover, they are easy to interpret into a computer. If well written and it is organized then you will be able to present your case within a few minutes. SOAP Notes are easy once you get the hang of them. So don’t stress as they will become habitual in your day to day workings.