How to write a SOAP Note Step By Step?
If you are a doctor or an assistant, you need to write SOAP notes. These documents the history of the patient’s symptoms and illnesses. By creating SOAP notes, you let the patient go to any doctor. This means that every specialist will be able to get acquainted with the person’s history and prescribe the necessary treatment.
In this article, we will teach you how to write a SOAP note if you are not experienced in it. We will explain what a SOAP note is and what its features are. Keep reading and expand your professional horizons.
What is the concept of the SOAP note?
If you see this name for the first time, do not get confused. SOAP is an abbreviation that is used to shorten the real name. Before we explain what, each letter means, let us tell you the general definition of the SOAP note. It is a type of document which is created for gathering patient’s data relating to symptoms and diseases.
SOAP notes are needed to inform doctors and pediatricians about human health. This describes what symptoms are inherent in the patients and what treatment they have taken. Based on data from SOAP notes, doctors determine which drugs affect the patient’s well-being and which ones are bad.
Let’s discuss what each letter means.
- S for Subjective
- O for Objective
- A for Assessment
- P for Plans
Now, we are ready to explore the definition of each part.
1. Subjective
As you can get from the name, it states what the patient feels. The first part is used for the client’s complaints and general symptoms.
2. Objective
These are objective observations of the well-being and symptoms of the client. In this section, the doctor describes the key symptoms, suspicions, and possible illnesses the patient has. Also, the doctor should add additional information that may help the treatment. This includes genetic predisposition, lifestyle, and patient habits.
3. Assessment
In this section, the doctor summarizes the data from the previous two sections. They describe their assumptions and patient diagnostic results. If the client’s symptoms relate to several areas of medicine, each specialist should write their assumptions.
4. Plans
This section contains suggestions for the treatment and further prevention of diseases. The doctor indicates his recommendations and the necessary measures to help cope with the problem.
Why do we need SOAP notes?
Before you find out how to write a SOAP note, it is important to learn the pros and cons of such a document. All hospitals and clinics should create their template for the SOAP note so that all doctors use it. When being diagnosed, the patient visits several specialists, and each one writes something in a SOAP note. If the document does not have a single format, doctors will be confused with patient data.
Well, you understand the reason for using SOAP notes. However, it’s worth noting that this file has both advantages and disadvantages. Let’s discuss them briefly.
Pros
The main goal of the SOAP note is to provide doctors with the necessary patient information. Such a document shows what symptoms the patient usually has. Reading the notes in the medical record, experts understand in which direction they need to move. Each doctor can also add information that relates to his specialization.
Another significant advantage is a single language that is understandable to every doctor. The main way to record information is abbreviations and acronyms. Thus, the description does not take up much space, and the SOAP note can be used for many years.
Cons
While SOAP notes are not inconvenient for doctors, patients are unlikely to be able to figure out the notes. Doctors and pediatricians try to write down information briefly and quickly, so you are unlikely to understand what is actually written. In addition to this, doctors have a rather specific style, which is understood only by themselves.
Despite some disadvantages, SOAP notes are considered a great way to record patient health information. Now you must learn how to write a standard SOAP note step by step.
How to write a SOAP from A to Z?
No matter how good medical care is, you need to know how to keep records. If SOAP notes are removed from the healthcare sector, the patient will not be able to change the doctor or get a full description of the diagnosis. If you ignore the documentation, this complicates the process of providing the service.
Some medical facilities use their documentation methods. However, this complicates the life of the patient since he is unlikely to be able to figure out the notes on his own. It also limits customers because they will have to go to the same clinic.
Critical Information You Have to Add to a SOAP note
You will not find a document or law that governs the way SOAP notes are maintained. However, you should add enough information about the patient’s health and aptitudes. Focus on the essential data that are needed to provide a general overview of the patient. Here is the list of data you should add:
- The story of the client, his complaints and concerns
- Types of treatment and diagnosis applied to the patient
- Medical equipment used in the treatment process
- How did the patient feel when taking the drug or with intervention?
- Individual body reaction
- What actions have improved/worsened the condition of the patient
- The methods that led to the elimination of symptoms and the transfer of the disease
- Customer Close People Data
To understand how to properly compose a SOAP note, you need to take time out of each part of the document. Let’s discuss how to work with each section of a SOAP note to fill the card correctly.
1. Fill the Subjective Section
Write down the information that the patient or his family provides. Listen to the person and write down what complaints they have and what they are worried about. Sometimes the symptoms are not as important as the person’s attitude to the problem. Record accurate phrases to correctly convey the nature of the problem.
Indicate complaints, pains, and symptoms of the patient. Add information about previous medical conditions that may have caused the problem. This will help you reach a reasonable conclusion by forming an objective section. Do not ask strict questions; instead, ask the patient to describe the problem in more detail.
Try not to interrupt the client so as not to confuse them. Do not conclude until the patient completes the story.
2. Fill the Objective Section
Record objective observations with accurate data. Indicate the treatment methods and equipment used in the treatment process. Indicate the amount of the drug, the frequency of use, and the reaction of the patient. Also, add enough information about medical conditions and side effects.
Be sure to specify ROM, palpation, and analysis results. Indicate the tests that have been performed. Record possible injuries that you have discovered. However, do not indicate the diagnosis if you are not sure about it.
3. Fill the Assessment Section
The assumptions of professionals should be indicated in this section. Analyze and correlate information from subjective and objective sections. Make a rough diagnosis and describe the problem in a professional language. Assign a few tests to determine the true problem. Based on the test results, prescribe the necessary treatment. Explain why you decided to prescribe a specific type of therapy.
Describe the reaction of the human body to the selected treatment. Add patient comments regarding his state of health. So, you determine which drugs act badly on the patient. Again, indicate accurate metrics instead of using common phrases. This will help other professionals understand the patient’s problem.
4. Fill the Plans Section
Indicate methods of prevention and treatment of the disease that will correct the patient’s problem. Write down the types of surgical interventions that are needed during treatment. Add recommendations to help get rid of your symptoms or ease them. Indicate the patient his bad habits that negatively affect his health.
Describe the time frame in which the patient’s health should improve. Choose indicators that should improve in the short/long term. Set a re-appointment date to determine if the patient is improving/worsening.
Some Tips to Help You Fill the SOAP Note
- Follow the established pattern of a SOAP note. Follow the sequence of elements and check your notes;
- add all key data. Do not try to fit patient information in a few lines. Indicate key information that affects further treatment;
- provide accurate data. If you can measure your health, write down the indicators. Do not use the words “strong”, “many”, “small” if you can specify the sizes;
- make it easy to understand. Every person who views that SOAP note should understand the content. Use standard terms and abbreviations.
We hope that our guide would be useful for you. Follow it step by step to create your first SOAP note. If you have any questions, feel free to contact us 24/7.
