If you have worked or are currently working in a hospital, you probably already know what a SOAP note is. If not, let’s learn all about it. SOAP notes are written documentation made during the course of treatment of a patient. A SOAP note template comes in a very structured format though it is only one of the numerous formats health or medical professionals can use. A SOAP note template by a nurse practitioner or any other person who works with the patient enters it into the patient’s medical records in order to update them.
It can also be used to communicate any data to other health care providers in case they don’t get a chance to speak verbally. It is essential as proof that the patient is being treated regularly and effectively by different people.
SOAP is actually an acronym and it stands for:
These also happen to be the different components of SOAP notes, which we will be discussing further in this article. SOAP notes are a type of documentation which, when used, help generate an organized and standard method for documenting any patient data. Any type of health professionals can use a SOAP note template – nurse practitioners, nurses, counselors, physicians, and of course, doctors. Using these kinds of notes allows the main health care provider to collect information about a patient from different sources, ensuring that the treatment procedures are accurate.
In this article, you will learn everything you need to know about SOAP notes – from the history, benefits, components to tips and steps in writing it yourself. First, let’s discuss a short history of SOAP notes and how they came to be.
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SOAP notes have been around for some time now and because of their efficiency and functionality, they are still being used now. The very first SOAP note template was created and developed by a brilliant doctor named Lawrence Weed way back in the 1960s. It was done at the University of Vermont as an element of the POMR (Problem-Oriented Medical Record). During those times, objective documentation did not exist so physicians had the tendency to make decisions about treating patients without scientific basis.
With SOAP notes, each note was made and connected with a concern which had been identified by the main physician, so it served as only one element in the whole recording process. However, because of the organized format of SOAP notes, a lot of other disciplines started to use it over the POMR, and so it gradually gained popularity.
SOAP notes gave doctors, physicians and other health professionals a way to communicate with each other using a structured and organized format. Early in the 1970s, those who had begun using these notes were able to retrieve patient information and patient records and use them for reference for other similar medical problems.
The structured and organized feature of SOAP notes made documentation and communication a lot easier and now, more modern methods are still deriving a lot of their aspects from the simple SOAP notes. Now, these are very common and are being used and practiced all over the world.
The history is short and sweet, but the benefits and sustainability is another story. In the next section, we will be discussing the different benefits of writing SOAP notes to record pertinent data about a patient.
As you’ve seen from the introduction and the history, a lot of people can write a SOAP note template, nurse practitioners, doctors, nurses and other health care providers in charge of treating patients. It is very beneficial to write down notes to keep track of and record the progress of treatments of patients.
Here are the different benefits of writing SOAP notes:
As you can see, these benefits are good not only for patients but all other health care professionals involved. This is because it paves the way for them to be able to communicate effectively while keeping track of the whole process of treatment of a patient. Now let’s move on to the different components of a SOAP note template. Knowing these would allow you to get a better feel of how to write your own notes.
Knowing the brief history and many benefits of making SOAP notes has probably made you more interested in learning even more about them. As previously stated, SOAP is actually an acronym which refers to the different components which must be present when writing it. These components can be worded in different ways as long as you follow the format and make sure that what you are writing signifies the essence of each and every one of the components.
Here are the four major components which are found in a typical SOAP note:
The subjective component of the note would describe the recent condition of the patient, written in a narrative form. The major complaint of the patient would be written here and could be worded using the patient’s own words. This component mainly focuses on the reason why the patient came to the hospital or to the doctor in the first place. It could include (but doesn’t have to be limited to):
The objective component of the note would be a factual account of the patient and the patient’s status. This is a more objective look at the whole condition of the patient along with a record of the initial findings which have been made about the patient. This information can include (but not necessarily limited to) the following:
This component would contain the initial diagnosis of the physician based on the first two components. The main purpose of the patient’s medical visit is to seek treatment and so the assessment should contain all the symptoms stated by the patient along with the diagnosis of the illness or injury.
It should also include a differential diagnosis or a list of other likely findings, arranged in order of the most likely one to the least likely one. This would ensure that all possibilities are considered and nothing is overlooked. The assessment could also contain all the possible causes of the patient’s problem, especially if the patient is experiencing an illness.
If the patient had made a visit before, it should also contain the progress which had been made since the last visit as well as the overall progress towards fully treating the symptoms, based on the perspective of the main physician.
Any drug related issues or drug induced issues should also be included along with any evidence and reason behind it. The pharmacist can be the one to write a note about this. Any other risk factors, evaluation for therapy options should be included as well in order to make a detailed and comprehensive assessment.
This final component should contain whatever plan or process the physician will be doing to treat the patient and eliminate any health problems or concerns. If needed, further laboratory examinations can be done along with other examinations such as a radiological procedure.
Referrals to specialists can also be given, crucial procedures may be performed and medication (along with the supplemental education) can also be given to treat a patient. All these must be included in this component of the note.
If any kind of therapy is involved, the goals of the therapy should be specified along with any drugs which will be administered throughout the course of the therapy.
A plan must be made for each and every item in the differential diagnosis especially if the patient has more than one problem with his/her health. The plan would then specify which concern is to be addressed and treated first, based on the severity of the illness or concern.
Usually, the Assessment and Plan components are grouped together to make things a lot easier. A problem is stated alongside the treatment for it. These essential components must be present in all SOAP notes so that they are effective and can be added to the medical record of the patient. Now that you know all about SOAP notes, let’s move on to the most important part – actually writing your notes. You have to know how to efficiently write SOAP notes so that you are able to provide the relevant information to inform other physicians and ultimately help the patient as well.
Creating a SOAP note template is quite easy as long as you make yourself familiar with the different components as these would provide you with the framework for the note. If you are working in the medical field, it would be very useful for you to know how to write SOAP notes. Read on and be guided by these easy steps and tips:
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