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.
Pro tip: You can hire an expert to write the SOAP note on your behalf
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.
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.
Read on the section below to learn what you should include in your soap note template.
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.
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.
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.
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.
The plan is where you will use the previous elements to develop a treatment method. The section should have information pertaining:
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.
Since its introduction, the framework has been instrumental to health experts in that:
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:
A SOAP note is an essential part of every patient's treatment. To write a practical soap note, consider following the following tips:
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
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