SOAP note (acronym for subjective , destination , ratings , and plan ) is the documentation method used by health care providers to write notes in the patient chart, along with other common formats, such as entry records. Documenting patient meetings in a medical record is an integral part of a practice workflow that begins with scheduling patient appointments, for writing notes, to medical billing.
The SOAP notes come from a problem-oriented medical record (POMR), developed by Lawrence Weed, MD. Initially developed for doctors, who at the time, were the only health care providers allowed to write in medical records. Today, it is widely adopted as a communication tool among interdisciplinary health care providers as a way to document patient progress.
SOAP notes are usually found in electronic medical records (EMR) and are used by various background providers. Pre-hospital care providers such as emergency medical technicians can use the same format to communicate patient information to emergency physicians. Doctors, physician assistants, nurse practitioners, respiratory therapists, pharmacists, podiatrists, chiropractors, acupuncturists, occupational therapists, physical therapists, school psychologists, speech-language pathologists, certified athletic trainers (ATCs), sports therapists among other providers using this format for the patient's first visit and to monitor progress during follow-up care.
Video SOAP note
Components
The four components of the SOAP record are Subjective, Goal, Assessment, and Plan. The length and focus of each component of the SOAP record varies depending on the specialization; for example, SOAP surgical records may be much shorter than the medical SOAP records, and will focus on issues related to post-surgical status.
Subjective components
Initially patients major complaints , or CC. This is a very brief statement about the patient (quoted) about the purpose of an office visit or hospitalization.
If this is the first time a doctor has seen a patient, the doctor will take the current history of the disease, or HPI. It describes the current condition of the patient in narrative form. The history or state of symptoms experienced is recorded in the patient's own words. All information relating to subjective information is communicated to the health care provider by the patient or its representative. This will cover all the related and negative symptoms under body system review . Medical history, surgery history, family history, and social history, along with current medications, smoking status, drug/alcohol/caffeine use, levels of physical activity and allergies, are also recorded. SAMPLE history is one method to obtain this information from a patient.
Subsequent visits to the same problem briefly summarize the current history of the disease (HPI), including the relevant testing of outcomes, references, treatments, outcomes and follow-up.
The mnemonic below refers to the information that the doctor should disclose before referring to the patient's "old chart" or "old cart".
- O nset
- L ocation
- D urate
- CH aracter (sharp, boring, etc.)
- A factors that drive/ A
- R adiation
- T the emporal pattern (every morning, all day, etc.)
- S everity
Variants on this mnemonic (more than one can be listed here) include OPQRST and LOCQSMAT:
- L ocation
- O nset (when and mechanism of injury - if any)
- C hronology (better or worse since onset, episodic, variable, constant, etc.)
- Q uality (sharp, boring, etc.)
- S everity (usually pain rating)
- M pollution factors (which aggravate/reduce symptoms - activity, posture, medications, etc.)
- A additional symptoms (symptoms are not related or significant to the main complaint)
- T reatment (does the patient see another provider for this symptom?)
Destination component
The objective part of SOAP includes information observed by health care providers or actions of present patient presentations, such as:
- Vital signs and measurements, such as weight.
- Findings from physical examination, including heart and respiratory base system, affected system, possible involvement of other systems, normal findings, and abnormalities.
- Results from the lab and other diagnostic tests are completed.
Assessment
Medical diagnosis for the purpose of medical visit on a specified date of written notes is a quick summary of patients with major symptoms/diagnoses including differential diagnosis, other possible diagnostic lists usually in the order of least possible for small possibilities.. This assessment will also include possible and probable etiologies of patient problems. This is the patient's progress since the last visit, and the overall progress toward the patient's goal from the doctor's perspective. In a pharmacist's SOAP notes, the assessment will identify possible drug/induced problems and the reasons behind it. This will include aetiology and risk factors, assessment of therapeutic needs, current therapy, and treatment options. When used in problem-oriented medical records (POMR), the relevant issue number or title is included as a subheading in the assessment.
Clinical psychologist Barbara Lichner Ingram, in her book on clinical formulation, uses the word "hypothesis" instead of "judgment", which produces SOHP acronym instead of SOAP.
Plan
The plan is what will be done by health care providers to treat patient concerns - such as ordering more laboratories, radiology examinations, referrals given, procedures performed, medications provided and education provided. The plan will also incorporate the therapeutic goals and parameters of disease monitoring and disease-specific patients. This should address each item of the differential diagnosis. For patients who have some of the health problems discussed in SOAP notes, plans are developed for each problem and assigned an appropriate number based on the severity and urgency of the therapy. A record of what is discussed or recommended with the patient as well as the timing for further review or follow-up are generally included.
Often the Assessment and Planning sections are grouped together.
Maps SOAP note
Example
A very rough example follows for patients who are reviewed after appendicitis surgery. This example resembles a surgical SOAP record; Medical records tend to be more detailed, especially in the subjective and objective sections.
Source of the article : Wikipedia
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