How to Write a SOAP Note: A Simplified Guide

By Nicole, 19 May, 2020

The patient history medical professionals take determines the kind of care that patients will receive. Taking comprehensive, informative, and concise notes is a technique that takes time to master. Fortunately, using a framework like the SOAP note in your patient can assist boost clinical documentation and arriving at the primary diagnosis.

What is a SOAP Note?

As previously noted, a SOAP note can be defined as information about a patient that is presented and written in a particular order. Pioneered by Lawrence Weed, it is used for medical histories, admission notes, among other documents in patients' charts.

So, what does SOAP note stand for?

Typically, it involves four (4) elements that match all letters in the acronym that is; Subjective (S), Objective (O), Assessment (A), and Plan (P). The four elements remind physicians of the details they should gather when taking patient history.

How to Effectively Write a Soap Note

Read on the section below to learn what you should include in your soap note template.

Subjective

This step involves gathering information that a patient shares about their signs and symptoms. Normally, your patient will give you an account of their experience, condition, and symptoms. They will tell you what they think will be their treatment goal and needs.

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A summary should consist of the patient's direct quote. Avoid paraphrasing your patient's words. It will help in understanding the health condition better. Remember to take note of all comments your patient and their loved ones make.

The subjective element forms the basis of the notes and the treatment plan. Therefore, getting the most information is essential. The acronym "OLD CHART" offers the most effective method to address your patient's condition thoroughly.

Onset- Enquire when all symptoms started

Location- Learn the location of discomfort and pain

Duration- How long has your patient dealt with the symptoms

Character- Analyzes the forms of pain, including stabbing, aching

Alleviating/aggregating factors- Learn what reduces or intensifies the seriousness of the symptoms

Radiation- Does the pain radiate to other body locations?

Temporal pattern- Enquire whether the symptoms manifest in a pattern like after meals or in the morning.

Symptoms related- Secondary symptoms and signs

Objective

This element of the SOAP note format involves factual details. It can be an observation of your patient's body language, mood, appearance, and behavior.

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Make sure you write as many details as possible. This phase should focus on raw data (instead of your conclusions and diagnoses).

Objective phase assists in differentiating between signs and symptoms. Symptoms are a client's experience of the condition. Signs, on the other hand, are objective observations linked to the condition. For instance, if a patient claims of having anxiety symptoms, they will experience a pain attack. Signs of anxiety include hypertension and visible trembling.

Assessment

The above-discussed elements are instrumental in this stage. Here you'll document your impression as well as interpretation using the details you have collected. During the initial appointment, the assessment part of the note might or might not take in a diagnosis founded on the type and seriousness of the signs observed and symptoms reported.

When it comes to common health conditions, the assessment is simple and can result in diagnosis after the initial consultation. Whereas for complicated conditions, you might require time to collect information on objective and subjective phases before reaching a diagnosis.

During follow-up appointments, the assessment element comprises an assessment of your patient's progress. It will inform you of both the current and future treatment plans.

Plan

The plan is where you will use the previous elements to develop a treatment method. The section should have information pertaining:

The treatment administered throughout the session and reason for using it

The patient's response to treatment administered

The date of the next appointment

Recommendation issued

Make sure the plan notes include an actionable note for all diagnoses. In layman's language, if a patient has several conditions, the notes should have plans for every disease.

The purpose of the plan is to address all specific conclusions made in the previous element. If correctly done, the plan improves your patient's ongoing treatment. It also gives other medical practitioners more information, especially during referrals.

What are the Benefits of SOAP Notes?

Since its introduction, the framework has been instrumental to health experts in that:

It improves connectivity- More and more primary caregivers and psychiatrists are rapidly adopting electronic health records. The software makes integrated health care possible. It permits physicians to gain access to each other's patient notes. Using a SOAP note template helps different specialists communicate with ease hence offering better care to all patients.

Accuracy- Following a soap note format increase your notes' accuracy. Instead of recalling what took place in your previous appointment, the notes allow you to structure appointments, obtain information quickly, and recall easily.

Soap Note Template Example

You can use a SOAP note format into any notes. To understand how you can integrate these notes in your practice, here is an example that clarifies as well as simplifies your documentation:

Subjective: Mary is aged twenty-one. She claims that her throat is sore, she has a fever for four days, and her body hurts. Before this, she had whooping cough and common cold.

Objective: Mary has a temperature of 39 degrees. She also has swollen lymph nodes, red throat, and rashes.

Assessment: The patient has a history of whooping cough and common cold and reports of fatigue, fever, and a sore throat. Clinical examination shows the existence of white patches on her throat and bacteria pharyngitis because of swollen lymph.

Plan: Prescribe acetaminophen for five days. Take a lot of water. Follow up after five days should the symptoms worsen or persist.

Tips for Writing a SOAP Note

A SOAP note is an essential part of every patient's treatment. To write a practical soap note, consider following the following tips:

Avoid writing notes during all sessions. Instead, write down short notes that will assist you to recall what your patient had said

Use a professional voice- For instance, avoid claiming that the patient had a blast at the time of the therapy session. The term “had a blast” is neither descriptive nor formal. Instead state that the client laughed and smiled throughout the session.

Be precise- It prevents confusion and boosts your patient’s treatment.

Be concise- Be sure to use proper grammar, active voice, and avoid wordy statements. Moreover, be brief. That way, your SOAP note is easy to read and improves communication with your colleagues and future medical practitioners.

Avoid judgmental statements- Make sure your notes are professionally done and neutral. In other words, focus on offering correct details and avoid overly negative or positive wording.

Don't include names of people named by the patient- Instead use initials when referring to the person the patient is talking about. That way, you make it clear to your colleagues to understand that the patient is the center of treatment. Additionally, it safeguards the privacy of other people.

Without a shadow of a doubt, a SOAP note helps keep the process consistent and clean. When well used, it ensures effective documentation and offers an evaluation and clinical consideration method. If you need help with your SOAP note, simply visit our essay writing service