10+ Best Medical SOAP Note Examples & Templates [Download Now]

A medical professional’s scope of work is a lot more complicated than what you imagine it to be. In addition to providing treatment to patients, doctors, dentists, therapists, and nurses also have piles of documents sitting on their desks by the end of each shift. One of which includes the medical SOAP note. The note is a highly structured format required to communicate information to other healthcare providers, to provide proof of contact with the patient, and to document the procedure taken for treatment.

Medical SOAP Note Examples

1. Infant Medical SOAP Note

The body of an infant is extremely delicate and sensitive to any infections, diseases, or injuries obtained. This is one of the reasons why parents and guardians are strictly advised to have their child checked once certain symptoms become apparent. Medical practitioners typically conduct a series of tests to clear the infant before he or she may be taken home. Infants who were born prematurely, for instance, have to be monitored by the hospital’s staff members for the time being. Medical SOAP notes and growth charts are just a few of the important documents filed by pediatricians and nurses upon the infant’s evaluation.

2. Labor & Delivery Medical SOAP Note

Every case at the hospital demands the time and attention of the staff on duty, especially when dealing with cases of labor and delivery. Although expectant mothers go through similar experiences, medical professionals still need to keep a close eye on every patient. A medical SOAP note is written to report on the patient’s current status for further evaluation. This will also help determine whether the mother has made any progress or regress after a specified period.

3. Medical Examinee SOAP Note

Medical examinations can be scary for patients who are eager to find out if there’s anything wrong with them. But to a health professional, it’s all in a day’s work. A SOAP note is often used to document this assessment. It can be as brief or as detailed as possible, depending on the amount of information that needs to be acquired.

4. Medical Massage Therapy SOAP Note

In spite of our ability to do just about anything, the human body does have its limits. Strenuous activities and the lack of proper rest can often lead to muscle pain and other similar conditions. Patients who experience these symptoms are often forwarded to a massage therapist who may help them recover. Massage therapy is highly recommended to relieve pain, rehabilitate sports injuries, provide relaxation, and address anxiety and depression. To help meet these objectives, medical SOAP notes are included in a report.

5. Medical SOAP Note of Patient

Even though SOAP notes are shared among professionals in the medical field for the purpose of study and advancement, these documents mainly focus on the better treatment of patients. Shown above is an example of a medical SOAP note that discusses the present state of a patient who came to the clinic to seek answers for a few complaints. Practitioners tend to go into detail with their analysis to gather a sufficient amount of information for their records.

6. Nutrition Medical SOAP Note

Living with health issues is never easy. You could be put on a meal plan, an exercise regimen, and prescription pills for the rest of your life. Seeing a professional to help you with your struggles is one way to get by. A nutritionist may provide you with some guidelines to prevent your health from deteriorating and causing further problems. To determine which program will suit your condition and assess whether or not it is effective, a medical SOAP is written for documentation and reference. The information found in the medical note may also be discussed with other healthcare personnel to offer proper treatment.

7. Pediatric Medical SOAP Note

Being a pediatrician, you deal with various patients who face different types of conditions. But because infants, children, and adolescents can be quite vague with how they express their feelings, creating a medical SOAP note has proven to be a challenge. In such cases, you may have to consult the patient’s parent or guardian for further details. The doctor’s note is essential to aid the healthcare provider in their diagnosis.

8. Post-Surgery Follow-Up Medical SOAP Note

Patients who have undergone surgery for a major or minor problem are likely to stay at the hospital at the doctor’s advice. That’s because some patients require post-surgery treatment due to a few complications, while others still need to be assessed during their recovery period to see whether the surgery was a success. Monitoring a patient during this time is crucial to one’s overall health. Thus, the SOAP notes made as a follow-up to the patient’s surgery must be written and studied carefully before any medical decisions are implemented.

9. Prenatal Medical SOAP Note

During your hospital trips to meet with an OB-GYN, you might have noticed your doctor take down a few notes for each assessment. Patients are often asked to discuss the symptoms that they have experienced since their last prenatal visit. If the doctor notices something serious or alarming about these symptoms, you may be advised to undergo a few more tests to see if the baby is doing all right. This is necessary to make sure that the mother and her baby are taken care of for the duration of one’s pregnancy.

10. Simple Medical SOAP Note

Most hospitals and clinics follow a standard format when it comes to producing a medical SOAP note. Apart from maintaining consistency, this also makes it easier for healthcare providers to read and find what they need from the document. The content of the note must be relevant and specific to the matter at hand, which is why most doctors and nurses try to simplify these records as much as they can. Fortunately, medical professionals are trained to report and understand these notes to ensure the proper treatment of patients.