A SOAP note is a structured form of documentation that is used by healthcare practitioners to detail observations and patient care. It provides a standard for recording pertinent information regarding a patient or client so that practitioners are able to efficiently evaluate the information and make an informed decision regarding the treatment of a patient. A SOAP note also gives healthcare practitioners a method for communicating clearly with other practitioners from other healthcare specialties and fields and can enhance the quality of care a patient or client receives.
SOAP is an acronym that represents:
- Subjective – information the patient or client provides about their condition
- Objective – the impartial observations of the practitioner
- Assessment – an analysis of the proposed diagnosis
- Plan – the course of treatment need to achieve stated goals
A Brief History
SOAP notes evolved from a similar method of medical documentation called POMR, or problem oriented medical record, a method that was created by Dr. Lawrence Weed M.D. in 1964 at the University of Vermont. POMR was used to consolidate the records of a patient’s medical issues from a variety of different sources into a single, concise and well-defined record.
When SOAP notes were first instituted, they were used only by licensed physicians, the only medical professionals with the authority to make notes in a medical record. Today, SOAP notes are used by a wide range of healthcare practitioners to detail their encounters with patients and to note their patient’s progress. It has also been integrated into other forms of medical record keeping, including electronic medical records.
Who Uses SOAP Notes?
SOAP notes are used by professionals in every field and aspect of the healthcare industry. This is because they serve as an easily recognizable form of communication that can be easily read across all disciplines of healthcare, all of which have varying healthcare objectives for patients and whose methods of documentation can differ widely. A non-exhaustive list of healthcare practitioners who use SOAP note includes:
- Emergency medical technicians
- Acupuncturists
- Physicians
- Surgeons
- Physician assistants
- Nurse practitioners
- Psychologists
- Pharmacists
- Chiropractors
- Occupational therapists
- Physical therapists
- Speech-language pathologists
- Behavioral health counselors
- Podiatrists
- Sports therapists
The Four Components of SOAP Notes
The exact format of a SOAP note will differ with each healthcare specialty. Individual healthcare organizations, hospitals, department within the hospitals and the practitioners themselves may require a specific style and content for a SOAP note. For example, an acupuncture SOAP note may differ significantly than a psychology SOAP note. An acupuncturist can only make diagnoses within his or her scope of practice and will not suggest treatments that are performed by a physician, surgeon or chiropractor. However the different the formats may appear, the four elements of a SOAP note, which include subjective, objective, assessment and plan, as well as the overall type of information required for each section, will be the same.
A typical SOAP note may provide the patient’s or client’s name, a case or patient number, the beginning and ending times of the appointment, the current date and the appropriate codes for procedures or other diagnostic tools. The rest of the SOAP note will clearly divided into four separate sections or paragraphs, with one section corresponding to each one of the four components of a SOAP note.
What follows is a detailed description of the four components of a SOAP note. Each section will include an example of how that part of a SOAP note may be completed by an acupuncturist.
The Subjective Component
The subjective element of a SOAP note includes what the patient or client or his or her caregiver states about his or her condition. When a practitioner inquires about the patient’s condition, open-ended questions should be used to glean as much detail as possible. The information that is recorded should include the client’s main complaint, a description of symptoms and past history. When noting what the patient or client is stating about the symptoms he or she has been experiencing or any other important revelations, the practitioner can include a brief, direct quote from the patient.
The background or history of the condition may comprise a major part of the subjective section. If the appointment is the first encounter between the practitioner and the patient, a complete history of the condition may be required. It can include a medical history, history of family diseases, allergies, whether or not alcohol, drugs or caffeine are routinely consumed, and more. During additional visits for the same medical issue, the history may include any treatment, tests or procedures the patient has undergone and their results.
When completing the subjective section, the practitioner should avoid documenting information that is irrelevant to the visit. He or she should also avoid being critical or passing judgement on the patient.
Sample of a Subjective Entry by an Acupuncturist
In the example in which an individual is seeking the services of an acupuncturist, the subjective portion of a SOAP note may include:
S: Patient is an adult male who has been experiencing anxiousness with Southern advance. Patient also states he has insomnia most nights and feels tightness in the chest.
The Objective Component
The objective portion of the SOAP note will detail the unbiased observations of the practitioner. If there are diagnostic exams or procedures that have to be conducted, it is documented in this section. The information should detail any measurable results of the symptoms, including those that can be heard, touched, smelled, felt or seen. Depending on the specialty of the practitioner, this section may contact information, such as:
- Blood pressure, heart rate, temperature, respiratory rate and other vital signs
- Measurements, such as weight and height
- Range of motion
- Report typical or abnormal findings from physical examination
- A list of medication as provided by medical or pharmacy records
- Outcomes from diagnostic or laboratory tests
While concise detail is important in every component of the SOAP note, it is particular critical for the objection section. The information provided in this section may form much of the foundation for the decisions made regarding the patients care and should be accurate and focused. The clinician should avoid writing down broad summaries or generalizations.
Sample of an Objective Entry by an Acupuncturist
In addition to the information already listed, an acupuncturist may will also examine a patient’s facial expression or countenance, scent, posture, voice, and tongue. An acupuncturist may detail his or observation as:
O: Tongue: Patient has a red tongue tip. Pulse: Patient presents with a tight pulse.
The Assessment Component
The assessment portion of SOAP note is where the practitioner will provide his or her diagnosis of the patient’s or client’s condition. The cause of the condition, any associated risk factors and the current treatments that are in place are also included in this section.
More than one diagnosis can be provided. If a definitive diagnosis has not been confirmed or established, possible diagnoses can be provided in a list that begins with the most likely diagnosis to the least likely. There should also be a mention of the diagnoses that have been ruled out. This section can also include information regarding diagnostic tests and any referrals made to other practitioners. If it is not the patient’s or client’s first visit regarding their condition, the practitioner will also provide an assessment of the progress the patient or client has made toward his or her wellness goal.
All of the information in the assessment section will offer the professional opinions of the practitioner based on the results of the objective and subjective inquires. The explanations of the analysis behind any assertions made should be clear and supported by facts.
One of the mistakes that can be made in this section is being too vague. It is also important to provide as much insight as possible when providing reasoning regarding the assessment.
Sample of an Assessment Entry by an Acupuncturist
A: TCM DDX: Shen disturbance
The Plan Component
In this section, the practitioner will detail the specific steps that will be taken to treat the patient or client. This can include short-term and long-term goals and treatment plans. Depending on the practitioner’s field of healthcare, the treatments may include therapy, surgery, medication, suggested changes to lifestyle, counseling sessions or more. The plan should be able to address every element of the diagnosis or diagnoses, and it should serve as a daily guide until the course of treatment has been completed. Discussions with the patient regarding the plan should be noted as well as times when there should be follow-up appointments or the case should be reviewed.
As mentioned before, the length and specific content of SOAP notes will vary among the various healthcare specialties. In some healthcare specialties, the assessment and plan components may be combined.
Sample of a Plan Entry by an Acupuncturist
An acupuncturist will have to note exactly which acupuncture points he or she uses. Other procedures that are used to treat a patient, such as massages, herbal treatments, cupping, moxa or the application of a heating pad, will also have to be noted.
P: Needle Plan: Herbal Plan: Gan mai da zao wan
At some point in time, a SOAP note that is completed by one healthcare practitioner will be read by another practitioner, possibility from another specialty. While it is important that a SOAP note provides enough detail that a practitioner who subsequently has to read the information will have no issue with understanding the intent of the writer of the note, it is not intended to have as much details as other forms of medical documentation, such as a progress report or an admittance form. The practitioner should be able to convey his or her message using precise, partial sentences and the relevant abbreviations, although attention should be paid to the use of abbreviations since they can be different for each healthcare specialty.
It is important that a SOAP note is written well and contains all of the information necessary for another professional to make sound decisions regarding patient care. Short and precise SOAP notes are more the standard than those that are excessively wordy.
SOAP notes have become an integral part of medical records and provide healthcare professionals with a standard of medical documentation that can be easily assessed and understood. Practitioners are urged to follow this standard when detailing patient encounters. In the next blog post, we will discuss the best practices in taking SOAP notes.
Sources
- http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2911807/
- http://www.physiciansoapnotes.com/
