The medical record is a foundational principle of patient care. SOAP notes are used by health care professionals to document a patient's medical problems and lay out a plan of treatment. The acronym stands for Subjective, Objective, Assessment and Plan. Not only are they used by physicians and nurses but also by other health professionals such as physical therapists and massage therapists. An explanation of SOAP notes using the most common format for writing them is given here.
Subjective and Objective
The subjective portion of a medical report is where the history of the patient's illness is documented. This usually includes events that led up to the present illness or injury, length and severity of symptoms as well as a discussion of what makes the problem better or worse.
The patient is asked to detail past medical history and sometimes family history as well as smoking, drinking and eating habits. Some of this information may be taken from the past medical record if patients are unable to give it themselves due to problems such as poor memory or unconsciousness. A friend, family member or legal guardian may also be asked to provide details.
The objective section usually includes a report of the physical examination given in the office. The patient's vitals are measured including blood pressure, height and weight. This is also where laboratory data will be reviewed such as blood work and x-ray results.
Assessment and Plan
In the assessment, the patient's current illness is listed with the probable diagnosis based on the subjective and objective information given. Past illnesses may also be listed here, especially if they have some bearing on the present problem and are current issues for the patient.
The plan lays out the steps that will be taken to treat the patient. This includes further lab tests that will be ordered and prescriptions given. If a clear cause cannot be established for the current symptoms, the plan will mention that as well as possible consultations needed with specialists.
Followup office visits based on the illness will be advised. The assessment and plan is where the health professional records whether emergency intervention was necessary and if the patient was transported to a hospital emergency room or advised to present to one.
SOAP Note Versatility
SOAP note writing is a skill taught early on to students in various health-related careers. The SOAP note is such a standard in medical records that it's used in everything from clinic reports for the common cold to hospital records of more serious problems.
SOAP is also a popular format for software for electronic medical records which are quickly becoming the norm for documentation of patient information. While it's a relatively simple type of report, the SOAP provides an overriding versatility that translates easily to all members of the health team which aids the efficiency of patient care.
Source:
Introduction to Writing a SOAP Note. Friendship Clinic, 2007.
Patricia Deneen - Patricia Deneen works at home doing medical transcription and web content writing. She was a professional massage therapist for 10 years ...
