How Do You Write a SOAP Note?

How Do You Write a SOAP Note?


What Is SOAP Note?

A SOAP note is a method of documentation employed by heath care providers to specifically present and write out patient’s medical information. The SOAP note is used along with the admission note, progress note, medical histories, and other documents in the patient’s chart.

Why Is the SOAP Note Format Important in Healthcare?

The main purpose of having a SOAP note template & examples in any medical institution is to have a standardized format in organizing the medical information of the patient. If the health care providers in the same entity use different kinds of format, It can get confusing when other review it.

The Importance of SOAP Note

As mentioned above, one of the main purposes of having a SOAP note is to have a standard way of documenting patient’s information. Not only does it facilitates a standard way of documenting, the SOAP note format also helps and guides the health care providers to understand the main problem of the patient and for them to accurately diagnose and treat the patient.

The SOAP note employs general familiarity of medical terms within the field of healthcare. And it also emphasizes clear and well-organised documentation of the patient’s medical condition, including the findings and lab results.

The Components of a SOAP Note

The SOAP stands for subjective, objective, assessment plan, plan.

  • Subjective. This describes the patient’s self-report of their current condition in a narrative form.
  • Objective. This outlines the objective observation of the condition and details all information and factors that can be measured.
  • Assessment. The assessment is the diagnosis or conditions the patient has. This also details the opinion of a therapist’s professional in regards to the subjective and objective findings.
  • Plan. This is where the health care providers plan on how to address the patient’s medical note condition and what they will do to treat the patient.

Tips on Writing a SOAP Notes

  • To make the briefing note effective, follow the format. Start from the subjective followed by the objective, then the assessment, and lastly the plan.
  • Make your SOAP note as concise as possible but make sure that the information you write will sufficiently describe the patient’s condition.
  • Write it clearly and well-organized so that the health care provider who takes a look at it will understand it easily.
  • Only write information that is relevant, significant, and important.
  • Only write jargon or medical terms that are already familiar or commonly used in the medical industry where you created the blank note.

Dos and Don’ts of SOAP Note

Dos

  • Make it concise, simple, and understandable.
  • Follow the SOAP note format properly.
  • Write all relevant information in the SOAP note in pdf.
  • Write the SOAP note legibly.
  • Document the condition of the patient immediately after the patient expressed his/her conditions.

Don’ts

  • Create long, exaggerated, and irrelevantly informational note template.
  • Have too many goals and objectives in documenting.
  • Use jargon and medical terms that are not common in the medical industry.
  • Write all the information in vague and uncertain in the SOAP note.

For more information regarding the SOAP notes, check out this article on “What is a soap note?