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.
Objective: This area shows the patients status and facts ie: vital signs, examination results, lab results, patients measurements and age.
Assessment: A brief statement of medical diagnose for a patients medical visit on the same day the SOAP Note is written.
Plan: This area shows what is going to happen from this point forward with a patient;,ie medications prescribed, labs ordered, referrals..etc..
Printable SOAP Note Format
SOAP Note Example
SOAP Note Sample
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.