19+ SOAP Note Examples – PDF


Health care providers, such as doctors, clinicians, physicians, and nurses as well as medical interns use a SOAP note to communicate effectively to their colleague about the condition of the patient that is crucial when providing a diagnosis and giving medical or surgical treatment. In this article, we are going to discuss the fundamentals of SOAP notes. Continue reading to broaden your thoughts pertaining to these documents and enhance your skill in writing one.

SOAP note facilitates a standard method in documenting patient information. When everyone on the medical fields uses different formats, it gets confusing when reviewing a patient’s status and may result in a bad and incorrect diagnosis and treatment. To make everything easy for them, SOAP note example is the default format they use in writing notes and presenting patients.

Psychiatric SOAP Notes

Psychiatry Follow-Up SOAP

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Psychiatric SOAP Example

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Surgery SOAP Note

Post surgery Follow-Up Note

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Daily SOAP Note

Daily SOAP Sample

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Asthma SOAP Note Example

Asthma SOAP Note

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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

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Patient SOAP Sample

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Prenatal SOAP

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SOAP Note Sample

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Physician SOAP Note

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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.

1. Subjective

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.

You may also see loan note examples & samples.

2. Objective

This portion documents measurable data, this involves data that you can hear, smell, see and feel. This also includes the 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
  • Results from physical examinations, such as posture, bruising, and abnormalities
  • Lab results

You may also like welcome note examples and samples.

3. Assessment

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.

4. Plan

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.

Psoriasis SOAP Sample

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Pediatric SOAP Example

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SOAP Note Format

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Clinical SOAP Note

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Orthopedic SOAP Example

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SOAP Note Example

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SOAP Note in PDF

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Sample SOAP Note

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Simple SOAP Note

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Basic SOAP Note

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Advantages and Disadvantages of SOAP Notes

A SOAP note is an effective document that is used to keep track of the progress of a patient. Respectively, this is divided into four portions which are the subjective, objective, assessment, and plan parts. However, just like any paper, its utilization has its own benefits and inconveniences. In this section, we will tackle both the advantages and disadvantages of SOAP notes.

Advantages

1. It is standard and traditional.

SOAP notes follow a standardized format in recording the medical situation of a patient and is utilized by health providers for how many years now. Thus, it is clear that most of the clinicians and other medical personnel are already familiar with this.

2. It is comprehensible and simple for clinicians.

Since a SOAP note uses a specific format that is distinctly divided into four sections, it would be much easier for the health providers to document the case of every patient. Furthermore, clinicians would also have a certain basis on which details and data they should consider in evaluating their subjects. They could also indicate the specific assessment and plan with their gathered information. Needless to say, the usage of SOAP notes greatly help medical professionals in a simpler manner.

Disadvantages

Nothing in this world is purely perfect, neither are the SOAP notes. Along with its advantages, there are also various difficulties that people encounter in using these documents.

1. It is topic-bounded.

Since SOAP notes only cater to the four major portions, there are specific topics that are merely included in this document. Accordingly, only the subjective, objective, assessment, and plan sections are considered in this paper. In fact, physiotherapists claimed that these documents are limiting their record of their patient’s condition. Particularly, these do not have any guidance to attain their practical objectives and results.

2. Assessment and Plan portions are often hard to locate.

In relation to its format, since the assessment and the plan sections are located at the end part, it could be a challenge for the medical personnel to locate the information included in these brackets. Even with the use of an electronic system, it would need several scrollings to view these pieces of information. This inconvenience could also be worsened by the lengthy content of the preceding sections.

3. It is time-consuming.

It also takes time to review and maintain a clean and updated problem list. Since its function is to evaluate the progress of a patient’s condition, changes are inevitable in the process. Thus, it needs to be regularly modified. Considering that these components are related to each other, some changes on the preceding portions could make a huge difference to the whole document.

4. Understanding it could be challenging for laymen.

Though these notes are comprehensible for most of the clinicians, the opposite seems to happen to most of the patients and people who are not part of the medical society. Due to its massive use of acronym, abbreviation, and jargon, it could be difficult for some laymen to understand these kinds of stuff.

A SOAP note has its own benefits that provide a community systematic documentation and evaluation of every patient’s condition. Nevertheless, on the other side of the coin are the shortcomings pertaining to its usage. Overall, SOAP notes have already been effective and useful; however, there will always be room for its improvement.

Tips for Writing a SOAP Note

Here are some basic tips for writing a SOAP note.

  1. 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.
  2. 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.
  3. Take your time in writing information that you need to include in your free note.
  4. 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.
  5. 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.
  6. 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.
  7. Use the standard SOAP format as this can help you to organize your notes effectively and efficiently.

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