Health care providers, such as doctors, clinicians, physicians, and nurses as well as medical interns uses a SOAP note to communicate effectively to their colleague about the condition of the patient that is crucial when providing a diagnosis and giving a medical or surgical treatment.
SOAP note facilitates a standard method in documenting patient information. When everyone one the medical fields use different formats, it gets confusing when reviewing a patient’s status and may result in a bad and incorrect diagnoses and treatment. To make everything easy for them, SOAP note example is the default format they use in writing notes and presenting patients.
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Psychiatric SOAP Example
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Daily SOAP Sample
Asthma SOAP Note Example
Asthma SOAP Note
What Is a Soap Note?
A SOAP note is a method of documentation employed by health care providers to write out data and records to create a patient’s chart, along with other documentation, such as the progress note. Health care providers including doctors and clinician use a SOAP note to have a standard format for organizing patient information as well as the patient’s medical conditions and issues. The SOAP acronym stands for Subjective, Objective, Assessment, and Plan.
How to Write a Good Soap Note
To write a good and effective SOAP note, you should follow according to the format.
- S— Write first the subjective portion (the “S”). Write your impressions on the patient. This includes the patient’s level of awareness, motivation, mood, and willingness to participate. Subjective also refers to the observations that are verbally expressed by the patient, such as the symptoms. You may also see field notes examples & samples.
- O— Followed by the objective portion (the “O”). This is where you write all the measurable data, such as vital signs, pulse respiration, and body temperature.
- A— Then the assessment portion (the “A”). The interpretation of the diagnoses or the conditions of the patient.
- P— Lastly, the plan portion (the “P”) This is where you write how you are going to address the patient’s problem. You may also like nursing note examples & samples.
SOAP Note Example
Patient SOAP Sample
SOAP Note Sample
Physician SOAP Note
The 4 Parts of a Soap Note
Let us take a closer look for a deeper understanding of the 4 part or stages of a SOAP note.
The subjective part describes the patient’s condition in narrative form. This is where you write your observations based on the condition or complaint which is expressed verbally by the patient or the reason why they came to see a doctor (doctor note)or physician.
The subjective portion includes:
- Onset: Determine from the patient when the first symptoms have started.
- Location: This refers to the part of the body where the pain is located (if the pain is present).
- Character: This refers to the type of pain endured by the patient (stabbing, sharp, dull, etc).
- Alleviating factors: What drugs, treatments, activities or posture aggravates/eliminates symptoms.
- Radiation: This refers to the place on the body where the pain radiates.
- Additional symptoms: If there are any related or unrelated significant symptoms associated with the main symptoms.
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This portion documents measurable data, this involves data that you can hear, smell, see and feel. This also includes patient’s condition or data that are repeatable and traceable.
- Measurements of the patient, such as age, weight, and height
- Vital signs
- Pulse Respiration
- Body temperature
- Result from physical examinations, such as posture, bruising, and abnormalities
- Lab results
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The assessment plan is the physician’s medical diagnoses or the condition of the patient. In some cases, the assessment may have one clear diagnosis, and in some other cases, it may include several diagnosis possibilities.
This is the last section of the SOAP note where you write how you are going to address the patient’s condition and problem. It may involve requiring an additional test to verify a diagnosis or a treatment that is appropriate to treat the patient’s medical note condition, such as surgery or medication.
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Tips for Writing a Soap Note
Here are some basic tips for writing a SOAP note.
- Write a thorough SOAP thank you note that you can refer during rounds. It is hard to remember specific things about each patient, such as lab results or vital signs.
- Organize your thoughts before writing a SOAP note. Ask yourself if do you have to write everything in the same orders as the patient expressed it.
- Take your time in writing information that you need to include in your free note.
- Do not overload your note with too much information. If you have the complete information to formal report, adding some irrelevant information will not help. If the patient feels no pain, you do not have to write it.
- You are writing for other health care providers. It is acceptable if you use medical terminologies and abbreviations to make your SOAP notes brief and concise. However, you must know what abbreviations are acceptable and understood. You may also see therapy note examples & samples.
- Your note should only last for five minutes when presenting it. If your blank notes are organized and well-structured then you can present it at least five minutes.
- Use the standard SOAP format as this can help you to organize your notes effectively and efficiently.