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.
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.
To write a good and effective SOAP note, you should follow according to the format.
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:
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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.
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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.
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.
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.
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.
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.
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.
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.
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.
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.
Here are some basic tips for writing a SOAP note.