The SOAP note stands for Subjective, Objective, Assessment, and Plan. This note is widely used in medical industry. Doctors and nurses use SOAP note to document and record the patient’s condition and status. The SOAP note is considered as the most effective and standard documentation used in the medical industry along with the progress note.
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The Purpose of a SOAP Note
The SOAP note template & example facilitates a standard method in documenting patient information. The purpose of a SOAP note is to properly document the patient’s condition and create a patient’s chart that is crucial in the diagnosis and treatment of a patient.
Who Uses SOAP Notes?
As mentioned above, the SOAP note is widely used in medical industry. The SOAP note is used by physicians, clinicians, doctors, psychiatrists, and nurses. Medical interns also use a SOAP note to make them familiarize with the note and give them knowledge on how to use it.
Components of SOAP Note
- Subjective. The subjective part details the observation of a health care provider to a patient. This could also be the observations that are verbally expressed by the patient.
- Objective. All measurable data such as vital signs, pulse rate, temperature, etc. are written here. It means that all the data that you can hear, see, smell, feel, and taste are objective observations. If there are any changes regarding of the patient’s data, it will also be written here.
- Assessment. The assessment is where the diagnoses of the patient are addressed and interpreted. The assessment plan should explain well the reason behind the decision to clarify the diagnoses expressed by the health care providers.
- Plan. The plan refers to the treatment that the patient need or advised by the doctor. Such as additional lab test to verify the findings. The changes in the intervention are also written here.
Guidelines for Writing a SOAP Note
Below are the basic guidelines in writing a SOAP note.
- Health care providers must follow the SOAP note format. It should start with the subjective, objective, assessment, and then the plan.
- The SOAP note must be concise and well-written. The SOAP note example is the tool used by all health care providers within a particular medical industry to properly diagnose and treat the patient.
- The SOAP note must record all the necessary information. The information in the SOAP note in pdf must be enough to understand the condition of the patient and must be sufficient in deciding what treatment is best.
- Medical terminologies and jargon are allowed in the SOAP note. This is to make the note concise and coherent. However, the terminologies and jargon must be known to all health care providers.
What Is the Difference between a SOAP and Simple Note?
The SOAP notes, as discussed throughout this article, is a kind of medical note used by health care providers to accurately document and record patient’s condition during treatment. The SOAP note is one of the few documentations used by health care providers. While the simple note is a note commonly used by many people to write down information so that they will not forget it.