Posted: February 9th, 2021

Complete Guide to Understanding SOAP Notes

During ward rounds, health care personnel (doctors, nurses, and students) need to record notes about the patient. This information needs to follow a laid out format, making it easy for any member of the medical team to understand the information. SOAP notes are a medical document which these medical practitioners use to record a patient’s information.

These notes are written in a particular order and consist of specific components. They record the patient’s history, notes taken during their visit to the hospital or on admission.

The main aim of SOAP notes documentation is to present information in a specific way that doesn’t confuse the medical team. New medical students may face difficulties writing SOAP notes. However, with our complete guide on SOAP notes, anyone struggling to grasp how to write the notes will have a better understanding.  

Introduction to SOAP Notes

SOAP notes are a widely used and accepted method that doctors and other medical practitioners use to structure notes for patients’ medical records. This noting system involved organizing patient information into four main categories- Subjective, Objective, Assessment, and Plan.

What Are the Four Parts of a SOAP note?

SOAP is an abbreviation for the four parts contained in a SOAP note

S- Subjective

O- Objective

A  Assessment

P- Plan

1. Subjective

This refers to notes that the doctor or nurse writes down after asking the patient why they visit. The patient’s medical history is noted down here.

The physician writes down their impression of the patient and then support these impressions with some observed facts. Subjective notes include interactions between the patient and the doctor, the patient’s feelings and concerns. In the case of physical therapy, it can consist of performance.

Under the subjective section, the medical practitioner needs to write the notes to back their impressions on the patient with observed facts. The facts can be symptoms, comments, or questions from the patient.

Remember, the last thing a nurse or doctor needs is working by a list of assumptions when treating a patient. Thus, the accuracy of the information is necessary to offer care to the patient.

Other things to include here include;

• Present illness
• Past medical history
• Social and family history
• Symptoms

Note: The subjective section of the notes is the most essential. It plays a major role in helping you evaluate the real injury. Therefore, it is recommended to avoid any questions that need a “Yes or No” answer. At all costs, avoid prejudging the patient, for example, concluding that the patient could be exaggerating their symptoms.

 

2. Objective

Here, the doctor or nurse will write down their findings after examining the patient. This is the section that includes concrete observations and numbers.

It can be measurable outcomes such as percentages of goals, test scores, and any score upon which is relevant. The objective section is more numbers-based as the doctor wants to avoid any excess amounts of supportive information, general statements, or impressions.

Here, you include;

• Temperature
• Heart rate
• Blood pressure
• Other measurable factors that have been used to track the patient based on the patient’s condition and physician’s goal.

 

3. Assessment

Under this section, the doctor will make his or her objective findings and note a diagnosis. This section allows the physician to be explanatory as they explain their professional evaluation of the patient’s condition.

The assessment section also acts as a wrap up of the individual’s visit or appointment. Therefore, physicians are urged to include interpretations about the session. For example, how did it go? Also, include the progress of the patient.

Medical practitioners are highly urged to avoid restating things that they may have earlier mentioned in the other sections of the patient’s notes. The SOAP noting system aims to remove any redundancy and prevent miscommunication.

Things to include under this section are;

• Patient diagnosis
• Progress
• Any changes in treatment or medication

 

4. Plan

It includes notes of the doctor’s recommended treatment plan for the patient. The plan also consists of any suggestions offered to the patient for recuperation.

However, this section should be left to record any changes made to the patient’s treatment plan. To avoid repetition, the care providers don’t need to rewrite their treatment plan whenever a patient visits the clinic or hospital.

This section can include changes in goals, activities, and medication. Therefore, you only need to rewrite the treatment plan from scratch only when the patient has not recorded any marked improvements over time.

Under this section, you should write;

• Lab test results or any other type of testing
• Procedures
• Referrals
• Prescriptions

How Do You Write a SOAP Note?

Healthcare workers use SOAP notes to relay clear and organized information about the patient to other medical professionals. These notes get passed along in the hospital to different practitioners. Therefore, you need to write them correctly by listing accurate information to help the patient get the utmost care.

Here are steps on how to write a SOAP note.

Part 1: Begin with the Subjective

1. Ask the patient about the reason for their visit

Talk to the patient and ask about their symptoms. Ask the patient what they are feeling to give you an idea of some of the signs he/she is experiencing.

See what their Chief Complaint (CC) is and write it down at the top of your SOAP notes. The chief complaint will help other healthcare providers to see the patient’s condition and to know what to expect as they continue reading the note.

Common examples of information you are likely to find in the subjective section are; chest pain, shortness of breath, or decreased appetite. If necessary, you can also talk to the spouse or the patient’s family member to get vital information.

Pro Tip: If the patient has many symptoms, pay attention to the repetitive sign. Pay attention to what the patient describes in detail to give you more insight into the main problem.

2. Use “OLDCHARTS” to gather helpful information

OLDCHARTS is a common mnemonic to help you remember the main questions to ask a patient during their visit. Asking questions in the mnemonic will help ensure your SOAP notes remain organized. Here is the mnemonic and what the letters stand for;

• Onset- when did the chief complaint begin?
• Location- where do you feel the chief complaint most? E.g., which part of the stomach hurts most?
• Duration- how long has the chief complaint affected the patient?
• Characterization- how does the patient explain the chief complaint?
• Aggravating/ alleviating factors- what makes the chief complaint worse or better?
• Radiation- is the chief complaint located in a single area, or is it mobile?
• Temporal patterns- does the chief complaint happen at a particular time, or does it happen throughout?
• Severity- ask the patient for the severity of the chief complaint. E.g., on a scale of 1-5, with five being the worst, how does the chief complaint feel?

3. Add any relevant medical or family history

Inquire from the patient if they have any previous medical conditions, allergies, or surgeries. In the case that they do, include the yeast of diagnosis and the doctor’s name who performed the surgery.

If the patient has any underlying medical condition, ask if the condition runs in the family to see if it could be genetic. When asking these details, only write the relevant information to the patient.

4. Take note of any current medication the patient is taking

Inquire if the patient is currently taking any medication, be it a prescription or an over-the-counter drug. If there is any, write down the medication, dosage, how the patient takes it, and how often they use it. In the case of multiple medicines, list each drug separately.

For example, Cetirizine 200mg orally every 5 hours for four days.

 

Part 2: Writing the Objective

1. Record any vital signs of the patient

Check the patient’s blood pressure, breathing, pulse, temperature and note them down. For accuracy, always double-check the score if they happen to either be lower or higher than average. Ensure the vitals scores are well-labeled to make it easy for other professionals to understand.

2. Write down what you gather from your physical examination

Based on the patient’s complaints, assess the main areas of complaints to help you write detailed observations. Rather than writing the patient’s symptoms, look for objective signs when performing your physical examinations.

For example, instead of writing “stomach pains,” be more objective and write “abnormal tenderness on the application of pressure.”

Pro Tip: If you can, take notes on a separate sheet when performing your examination. You can then transfer the notes after examination to ensure they are well organized.

3. Add result from any special tests you may have requested

Depending on how severe your patient’s concern is, you may need to request additional tests. For example, CT scans, ultrasounds and X-rays. If your patient has had special tests, add in any relevant results and may affect their treatments.

Always include lab results or photos to ensure other professionals see them first hand.

 

Part 3: Make Your Assessment

1. Record any changes in the patient’s problems

If the patient has come to the institution before, they may have a SOAP note in the system. Therefore, go through the note and make any changes you may have observed when tending to the patient. List if the change is negative or positive before having a treatment plan.

For example, if you have previously recommended an antibiotic, you may write down how the affected area has worsened or less swelling.

2. List down the problems according to the importance

If the patient mentioned several concerns, you should organize them according to their severity and importance. When you are not sure of the order of the problems, ask them what their main concern is.

3. Write down any diagnosis you can make

After listing the problem, note down the diagnosis. If there are various causes for the condition, list them all so that the first is the most probable call. Refer to your subjective and objective notes to speculate the leading cause of the problem.

4. Explain why you choose each of the above diagnosis

Write your reasoning for choosing the diagnosis by citing information from your notes’ subjective and objective sections. If you came up with multiple diagnoses, then explain how one could affect the other.

It is essential always to leave a description. It will help other healthcare providers going through the notes understand why you decided to settle for that particular diagnosis.

 

Part 4: Create a plan

1. State whether the patient needs to undergo more tests

Look at the diagnosis you wrote and decide if the patient needs to undergo more tests to confirm the diagnosis. Write down any necessary tests that align with the diagnosis and note them down in order of importance.

For example, if you may recommend a CT scan to determine if there could be any more causes for the patient’s pain. Also, have a recommendation section on the next course of action if the tests come back positive or negative.

2. Include any medications or therapy you deem necessary

If you think some form of therapy or some specific medication is necessary for the patient’s needs, include them. It could be mental or physical therapy or even rehabilitation.

In cases where therapy is unnecessary for the patient, you can write appropriate medication, dosage, and how long the patient should take it. Sometimes, the patient might need to undergo surgery, depending on how severe their condition is. In such a case, write it down.

3. Add any referrals to specialists

If you are not a professional in the care area that the patient needs, it is essential to write a referral to a specialist. Include the references for whom to get in touch with. Provide names for the diagnoses you have made. Also, keep the patient in the know to ensure they stay informed.

Format of A SOAP Note

Following the steps above, you will write down your SOAP note as it should be. However, after writing, you need to ensure the formatting of your SOAP note is correct. Here is how;

1. Ensure the patient personal details are at the top

Patient details such as their age, sex, and the reason they came to seek treatment should be at the top. For example, you can write; “32-year-old-female presenting with abdominal cramps” as the first thing in your SOAP note.

2. Organize your notes in order

You should always write down all the information you collected while attending to the patient. Ensure the information follows the Subjective-Objective-Assessment-Plan order to avoid miscommunication.

When writing the notes, you can choose to use paragraphs, sentences, or bullet points.

Pro Tip: Make sure you only use medical terms and abbreviations that are easy to understand to avoid confusion.

3. Write or Type the SOAP note

Different organizations have different systems. Therefore, depending on the clinic or hospital you are in, you can either write or type the note. However, most health care facilities have a computerized system, making it easy to pass information around. Thus, different departments can access the information on time and remain organized without the clutter that comes with using paper.

How Long Should a SOAP Note be?

There is no specific or recommended length for a SOAP note. You should focus more on ensuring all the necessary information is recorded and is easy to read. When writing your SOAP notes, refrain from using many acronyms or abbreviations that could make the notes hard to read for someone else.

Also, ensure your sections are organized to avoid confusing any healthcare personnel reviewing the patient’s charts.

 

Why Do Medical Practitioners use SOAP Noting Format?

The main reason why standardized note formats such as SOAP notes are used is because they significantly cut down miscommunication.

For example, if two facilities use the same noting system, it won’t matter if the patient is receiving service from two providers. Both parties will be able to go through and understand the records. They will know where to find the information they need, which significantly cuts down on miscommunication.

Miscommunication has always had an adverse effect, the most common being medical malpractice. Great communication also helps fight physician burnout. It does this because when the notes are organized and structured so that physicians can easily understand, they can spend more time tending to patients.

Here is an example; a pharmacist needs to know what medication to administer to a patient. The pharmacist needs to access the patient’s record to understand what to administer.

With the SOAP noting system, the pharmacist can easily log in to the work computer, access the patient’s records, and go to the “plan” section.  Thus, SOAP notes offer a clear and concise communication method that is less likely to cause any form of miscommunication between healthcare workers

What is The Purpose of SOAP Notes?

SOAP noting process was developed by mental healthcare providers and medical practitioners in the 1960s. The new noting process was aimed at improving communication among medical professionals. SOAP notes were aimed at making the patient documenting and managing process easy.

Since its introduction in the late 1960s, the documentation process has been in use for decades. It helps to organize easy problems and turn them into easy to assess chunks. Thus, SOAP notes provide an easy and uniform way to track a patient’s medical records.

What are the Advantages of SOAP Notes?

• They provide a fast, efficient and easy way to locate and access a patients information
• The SOAP system makes it easy to identify problems and develop strategies to achieve the desired goal in the recommended treatment procedure
• This noting system offers substantial information regarding the patient’s medical history and their current medical condition. Thus, it helps medical practitioners to discuss and review.
• They give a clear idea to the doctor about the patient’s health condition, thus helping the doctor make a clear and effective diagnosis.
• This system is a professional way that helps build trust and credibility between the doctor and patient

Is There An Outline Of Information To Include In SOAP Notes?

• The patient’s report
• Essential details of the medical intervention
• The equipment used
• Any changes in the patient’s medical condition
• Whether any complications have occurred
• Note on whether the desired goal was achieved
• Any details of communication between the patient and other medical practitioners or their family members for advice and discussion

It is the role of nurses as well as doctors to take time and write their SOAP notes well. The details of this report will be accessed and used by other healthcare professionals. They can access the information either during the prevailing medical intervention or at a later date.

SOAP notes are an essential part of medical practice, which begins once the patient schedules an appointment and ends with medical billing. Aside from doctors, therapists (physical and massage) also use the same format to record and monitor their patient’s progress.

Tips To Remember When Taking SOAP Notes

1. Create an outline

   Always have a template to make it easy for you to write. If you are writing down instead of typing, leave blank spaces and fill them when tending to a patient.

2. Immediately record decisions

   To ensure accuracy, always write down details as you continue interacting with the patient. You might forget crucial information if you choose to write them later.

3. Seek clarification

   Always ask the patient to clarify any explanations you may not have adequately understood. Aim to be as specific as you can be when writing the notes.

4. Only record relevant information

   You cannot capture your interaction with the patient word for word. Instead, focus on writing down the relevant information only.

FAQs

Q: How do I record SOAP notes on hypothermia?

A: For the subjective section. You should always record the symptoms the patient is telling you. For example, “I feel extreme cold.” Under the objective section, write down what you observe. For example, “The patient is shivering and has blue lips.” The assessment will be your general observation. The plan can be Tx: Remove wet clothing, drink warm fluids, etc.

Q: What is the meaning of “active range of motions”?

A: This refers to any motions that the patient does by himself or herself. Passive range of movements will be motions you help them do or do for them.

Q: What should information should I avoid adding to the SOAP note?

A: You should always record everything. That way, during the patient’s next visit, the person attending to them will have full details of the patient and their history. Therefore making it easy and time-saving.

SOAP note example nursing

Consider this SOAP note example for nurses. If you recently enrolled in a nursing course, it could be challenging to understand how to write SOAP notes correctly without making any references. However, our guide above will help you understand everything and make your noting experience easier.

Should you need more help with your schoolwork, we are always glad to help. We offer nursing assignment help for students. UniHomeworkHelp is your one-stop solution for any paper writing or essay writing service you may need. Contact us today, and let us make it easy for you to achieve your dream career!

 

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