How to Write a SOAP Note
What is a SOAP Note – Definition
A SOAP note is a document usually used in the medical fraternity to capture a patient’s details in the process of treatment. This is one of the many formats that are used by professionals in the health sector. The SOAP note is usually included in the patient’s medical record for the purpose of informing any other health officer that will handle the patient, to act as evidence that the patient has been clinically assessed and to provide the clinical reasoning behind the same.
SOAP stands for the following:
S – Subjective
O – Objective
A – Assessment
P – Plans
Let’s look at these in details.
This is what the patient explains, basically where the problem is and is usually in form of narration.
This is what the health officers make use of the patient’s narration that is an objective observation of the patient’s problem. In this case, the health officer needs to put down all the information and aspects that should be looked out for.
Here the health officer looks at the various concerns of the patient. Apart from that, it includes the professional opinion of the therapists based on the subjective and objective findings.
These are the measures to be taken or the treatment needed to achieve the objectives.
Before proceeding, let’s have a brief look at the history of the SOAP notes.
The practice of preparing SOAP notes began in the 1960s. This was developed by Dr. Lawrence Weed a member of the University of Vermont. The purpose of the SOAP notes was to help in the problem-oriented medical record.
Now you are asking yourself, why we need SOAP notes.
Every medical institution needs to have a SOAP note example or template because it is very important for an institution to have a uniform format of organizing their patient’s medical information. This is for the obvious reason, if the institution has different formats, it can be very hard for someone else to understand the information in a patient’s chart. This clearly means that there are quite a number of advantages and disadvantages associated with the SOAP notes.
It has already been mentioned that the main purpose of SOAP notes is to develop a uniform way of capturing patient’s information in a medical facility. It is, therefore, true to say that, the SOAP note not only provides a standardized format of recording patients information but also it serves to guide the health officers on understanding the patient’s main issue and developing the most accurate treatment so as to provide better treatment.
Apart from that, the SOAP note adopts the use of medical terms that everyone in the medical field understands. With this, the health officers are able to organize the patient’s information in a clear and concise manner.
The common problem associated with the SOAP notes is that it employs the use of too many acronyms and abbreviations and that it is too concise which sometimes make it hard for people outside the medical fraternity to understand.
Physiotherapists also find SOAP notes quite limiting because there has been no guidance provided on how they can handle the functional goals or outcomes.
With that in mind, we can now get to understand how to write a SOAP note. You should bear in mind that this is just a simple document that includes only four main components as mentioned earlier.
Writing a SOAP Note Step By Step
It is important to note that documentation plays a major role in the process of providing health care services. However, in most cases, this aspect is highly ignored since most of health care providers choose to adopt methods that are not specific and sometimes giving a very brief description that is quite vague making it for another person to even comprehend.
In as much as there is no guidance on the length and details of patient’s information that should be documented, one should understand that they need to provide enough and relevant information based on the case at hand. The following are some of the guidance given by the American Physical Therapy Association on the nature of the information that should be included in a patient’s documentation:
- The patient’s self-report
- The details of the kind of intervention given
- The used equipment
- Patients response
- Any complication or negative reactions
- Factors that lead to an intervention change
- Achievement of goals or objectives stated
- Proper communication with other stakeholders i.e., health providers or the patient’s family.
As a health provider, you should always have in mind that your report will at one-point land in the hands of another health provider either when you are still handling that case or some years later when the patient seek health assistance. This, therefore, calls you to be cautious to ensure that you write it well. We have already mentioned the components of a SOAP note, it now time to have an in-depth look at them.
Writing the Subjective
In simple terms, this is the information provided by the patient in a narrative form about their problem in terms of the symptoms, disability, function, and history. It is therefore very detailed. This information not only comes from the patient, it can also be derived from other caregivers or family members.
Direct phrases should be used to quote exact phrasing in this case. The purpose of this component is to allow the health officer to document what the patient’s think about their condition in regards to their functional performance, rehabilitation progress or their quality of life. The following are some of the major things that you can find in the Subjective part of the SOAP note:
- c. standing for (Chief Complaint)
- description of pain
- Etiology MOI (Mechanism of Injury)
- Patient’s History
Points to note:
- This is the most important part of a SOAP notes as it will help you in the objective part when trying to get to the exact potential injury.
- Make sure you completely avoid any question that will result in a YES or NO answer.
- Do not pre-judge on the patient, for example, thinking that the patient is overreacting
- Make sure you only capture the relevant information. Don’t include information such as a patient’s complaint about the last therapist
Writing the Objective
This section includes anything that you observe as the health officer. Such aspects can be measurable. It should all the intervention measures such as the duration, frequency, and the used equipment. As the health officer, you need to document how the patient reacts to these interventions not forgetting their communication with the family or colleagues.
Some of the things that don’t miss out in the objective section are:
- ROM (Range of Motion)
- Palpation – soft and bony
- Manual muscular tests
- Special tests
Points to note:
- All special tests should be highlighted at this point
- Make sure you identify the possible injury here so that you can picture what the main problem
- Provide enough details
- Avoid the use of general intervention such as ROM since we have Active, Passive and Resistive Range of Motion.
This is another important part of the SOAP note as it involves the professional opinion of the health care provider based on both the subjective and objective findings. Here you need to provide a clear explanation of what made you choose one intervention over the other. You also need to provide the patient’s progress towards the objectives or goals set and also include any factor that negatively affects this progress and needs to be modified in terms of the frequency, duration or the entire intervention. You should also not forget to include any adverse or positive response.
Points to note:
- Avoid being general in the assessment as it will make it look vague. For example, stating that the patient is improving
- Provide enough insight on any issue
Writing the Plan
This is the last part of the SOAP note and it is about the interventions for the patient’s treatment. This should have the various types of treatment that the patient should be given such as the therapies, medication, and surgeries.
Make sure you include both the long-term and short-term plans. For long -term plans, you can recommend the patient to change his/her lifestyle.
This section can also contain the outcome that you expect to see from the patients based on the treatment provided. This includes things such as increase strength, pain reduction or ROM.
Points to Note:
- The plan is a guide that should be referred to on a daily basis until the treatment goals are achieved.
- There should be no vague description in the plan.
- Ensure that the upcoming plan is included
Tips on Writing a SOAP Note
Having gone through the basic facts of the components of SOAP note, here are some brief tips on how to develop an excellent SOAP note.
- Make sure you follow the prescribed format, you SOAP note should start from the subjective, and then the objective followed by the assessment and conclude with the plan. This will ensure that your note is effective.
- You SOAP not should be as clear and concise as possible. This is to say it should be brief enough but capture all the relevant information that sufficiently informs about the patient’s problem.
- It should be well-organized so that anyone else who will pick it up will have no challenges in understanding it.
- Only consider important or significant information.
- When using medical terms, ensure that they are ones that everyone in your institution is familiar with.
Having said that, here are some of the best practices in writing SOAP notes:
- SOAP notes should be legible, simple, concise and easily understandable
- SOAP notes should strictly follow the prescribed template
- SOAP notes should include only the relevant information
- The subjective part of the note should be captured immediately after the patient has explained his/her condition.
These are some of the things that are not expected from you while writing a SOAP note:
- Including irrelevant information
- Using medical terms that people in the medical field are not familiar with
- Including vague or uncertain information
- Having a long and an exaggerated SOAP note that does not follow the template.
Sample SOAP Note
The following is an example of a SOAP note:
Chief Complaint: 23-year-old male presents w/ a chief complaint of: “my lower left back jaw has been sore for the past few days”
History of Present Illness: Pt relates the history of swelling for past 3 days, asymptomatic previously
Med Conditions: Asthma
Past Sx: Ear Lac 2009
Social Hx: Tobacco +
Vitals: BP 123/78
Extraoral: (Asymmetry, Swelling, Erythema, Pain, Parathesia, TMJ)
No asymmetry, no swelling. Patient points to exactly to #17 (FDI #38) for pain extraorally
Intraoral: (Swelling, Exudate, Erythema, Hemorrhage, Mobility, Occlusion, Pain, Biotype, Hard Tissues)
#16 (FDI #28) Supra erupted and occluding on pericoronal tissues of #17.O #17 Partially erupted, erythematous gingival tissue, no hemorrhage, slight exudate, fetid odor, pain to palpation pericoronal tissues #17
- Asthmatic – exercise induced
- Smoker (1 ppd)
- #16 supraerupted and occluding on opposing gingiva
- #17 Pericoronitis
Plan: (Pericoronitis and timing of extractions can be controversial. This is for example purposes) 1. Extraction #16 today and/or operculectomy #17
- Antibiotics x 10 days (Pen/Amox)
- Extraction #17 –
- Motrin 600 mg Q4-6h x 4 days
- Tylenol 500mg Q4-6h x 4 days
- Percocet T2 prn pain – Do not operate vehicles,
- Follow-up (prn)
Treatment Rendered Today: Consent signed.
34mg Lidocaine + 0.017 mg epi. Operculectomy #17, Rx’d antibiotics, CHX 0.12% BID x 10 days, Reappointed for exo #17 under local anesthetic. Post-surgical instructions.
Having gone through this guide you are good to go when it comes to writing a soap note.