Health care providers, such as doctors, clinicians, physicians, and nurses as well as medical interns use a SOAP note to communicate effectively to their colleagues about the condition of the patient as it is essential when providing a cure for the diagnosis and giving medical or surgical treatment. In this article, we will discuss the fundamental of a SOAP note in general. Continue reading to broaden your thoughts pertaining to these documents and enhance your skills in writing one.
SOAP note facilitates a standard method in showing patient information. When everyone in the medical field uses different formats, it gets a tad bit confusing when a patient’s status is being reviewed. This may result in a bad or incorrect diagnosis or treatment.
A SOAP note is a method of documentation that is employed by health care professionals to write data and records to make a patient’s char, along with other documents. Check progress notes for more. 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. You should know that the acronym of SOAP is Subjective, Objective, Assesment and Plan.
To write an effective SOAP note, you must follow the format that is mentioned below:
The subjective part describes the patient’s condition in the form of a narration. This is where you make your observations based on the condition or complaint which the patient expresses verbally. This also shows why the patient came to the doctor in the first place for the doctor’s note.
The subjective portion includes:
This part of the note contains measurable data as this involves data that you can hear, smell, see and feel. So, dealing with your sensory organs. This also includes the patient’s condition or data that are repeatable and traceable.
You might also want to see welcome note examples and samples that would be of great help to you.
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 a SOAP note. This is where you write how you are going to address the patient’s condition and issues. It may also involve requiring an additional test or two, just to verify a diagnosis or a treatment that is perfect to treat the patient’s disease. Medical notes can be of great help to you as well.
A SOAP note is an effective document that can be used to keep track of the progress of a certain patient. Similarly, this is divided into four parts, which are subjective, objective, assessment, and plan. However, just like any paper, its use has both advantages and disadvantages. Let’s see both:
SOAP notes follow a format in recording the medical situation of a patient and this can be used by health providers. Thus, it is clear that most of the clinicians and other medical personnel are already familiar with this.
SOAP notes use 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 easily this way. Further, clinicians would also have a certain basis on which details and data should be considered while evaluating their subjects. They could also indicate the specific assessment and plan with their gathered information. Needless to say, the usage of these noted helps medical professionals.
Since SOAP notes only cater to the four major portions, there are specific topics that are barely included in the document. Accordingly, only the subjective, objective, assessment, and plan sections are considered in this paper. Physiotherapists claimed that these documents are limiting their records of their patient’s condition.
Concerning 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 needs several scrollings to view a few pieces of information. This inconvenience could also be worsened by the lengthy content of the preceding sections.
It takes time to review and maintain an updated and clean problem list. Since its main function is to evaluate the progress of a patient’s condition, change is unavoidable in the process. Thus, it needs to be regularly modified. Considering that these components are related to each other, some changes in the preceding portions could make a huge difference to the whole document.
Though these notes are comprehensible for most of 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 benefits that provide systematic documentation and evaluation to every individual patient’s condition. Nonetheless, on the other hand, there are shortcomings concerning its usage. Overall, this kind of SOAP notes is pretty effective and useful. though there is always room for improvement.
Here are some basic tips on how to write a SOAP note: