We encounter progress notes all our lives. We often see them in school, we know about them in class and of course we also know more about them with our line of work. What we don’t know is that there are a lot of kinds of progress notes and it would of course depend or differ with each job or with each place we may encounter them. This means that there is very little case that two kinds of progress notes would have the same detail word by word. Of course when it comes to people working in medical fields, their progress notes would slightly be the same but it does not necessarily mean that everything is taken word by word.
This is why when working in the medical field, whether it be a clinical job, a medical job or even a pharmacy, a SOAP Progress note is necessary. We know that regardless of what job or field of job you may be working for, you would always encounter progress notes. For those in the medical and healthcare fields, these kinds of progress notes have their own category and format to follow. The SOAP note helps by giving you the right information and the right details. Since this type of job is not a laughing matter, being able to know what to give and what not to give is crucial.
To start off let us first define the abbreviation SOAP. The S stands for Subjective, The O Objective. The A stands for the Assessment and the P is for Plan. Overall, this is what makes up SOAP. A SOAP progress note is a kind of note or a kind of report that medical employees such as nurses, pharmacists and even healthcare workers use in order to write down any progress that has been made by either their patients or by any person in charge of the case. In addition to that, a SOAP progress note is a useful tool when it comes to writing down what can be done and finding a solution for it when you have limited time on your hands as well.
This is why the purpose of having a SOAP progress note is to make sure that all your information that has been gathered or taken is placed within the note. The fact that you need to follow the SOAP format to be able to make progress and to be able to get some answers for your progress note. In addition to that, your progress note should also fall under the subjective approach, the objective approach, to be able to get the correct assessment and to finally find a plan to do it.
Being able to know what a SOAP Progress note is good, seeing as it is a useful tool to have. The only issue that may stop some from using it is that they do not know how to write using the format. With that case, here are some tips to write a SOAP Progress note.
The best time to start writing a SOAP progress note is now. Gather your thoughts and ideas. Take the learnings and the reflections you have learned and seen from the experience you have when you were given the chance to observe. This is often the best time to start as your ideas and your thoughts are still fresh. You are able to write the progress note easier that way.
Always and always keep and use a professional tone when you are writing at all times. This is not your simple daily notes that you can use any kind of tone you want when writing. This is a professional progress note that can be read by just about anyone. Keeping your tone professional is a must. Avoid using jargon that would make your progress note unprofessional.
Never state an opinion you have no idea about. Nor choose sides when writing the information of your SOAP progress notes. This is basically one way to start an argument, and you would not want to go down that path all because you chose to side with something or someone.
Assuming something simply to put in your progress note should be avoided. Never assume what you think is happening without putting evidence to back it up. Especially with your SOAP Progress notes. It should always be something to think about before you immediately assume something. Facts and evidence over word of mouth.
Last but definitely not the least, your SOAP progress note must always be clear and always concise. You have to take this into consideration, that a lot of people apart from you would be reading your note. If you think that your notes are easy for you to understand but people have difficulty trying to decipher it, then you must make sure it is easy for everyone to understand.
A SOAP Progress note is a kind of note or report that employees working in the medical, pharmacist or even healthcare fields use to take down the progress of a patient or a person.
The S stands for Subjective, the O is objective, while A and P stand for Assessment and Plan. These are the things that make up the entire or the general SOAP notes.
The progress note helps workers understand the status of their patients. The SOAP notes help healthcare workers, nurses and even pharmacists understand or at least know the status of the patient or the person and the necessary information needed before proceeding with any action.
This is how you are expected to write your SOAP progress notes. As long as you follow the tips, that includes what and what not to do when writing, you would be fine. Remember that evidence and facts back up your progress notes. Without them, it would be incomplete and hard to take seriously.