Documentation has become a critical part of care, and many techniques have been developed to ensure accuracy and efficiency. Today, many practitioners (clinicians, nurses, physicians, therapists, pharmacists, and other healthcare professionals) utilize these techniques to capture accurate and adequate information about their clients. The SOAP note is one of the techniques that these professionals have widely adopted to improve the documentation process.
In this blog, we will walk through the essential parts of a SOAP note and how to develop one.
What is a SOAP note?
A SOAP note is an acronym representing S – Subjective, O – Objective, A – Assessment, and P – Plan. Since its adoption in the 1960s, the SOAP note has gained significant acceptance among healthcare workers for systematically documenting patient information. The method helps healthcare professionals to assess, diagnose, and address patients’ needs based on the information provided by them or their family members.
Clinical Significance of a SOAP Note
Medical documentation is vital for ensuring safe and quality care. SOAP notes offer healthcare professionals a feasible and accurate way of capturing adequate patient data from their first visit throughout the care process. It provides a simple template to help practitioners to organize patient information succinctly and thoroughly. The SOAP note template provides clearly labelled sections to help capture relevant information in a way that is easy to follow during care. This helps maintain effective care coordination and ensure care continuity. Again, a SOAP note promotes clinical reasoning by guiding healthcare professionals through the assessment, diagnosis, and patient treatment processes. Therefore, every healthcare professional should accustom themselves to writing a SOAP note for better documentation.
Essential Parts of a SOAP Note
As indicated above, a SOAP note is an acronym for subjective, objective, assessment, and plan, which form the essential parts.
Subjective: This section includes the main reason a patient visits the clinic. The chief complaint, history of present illness, medical history, surgical history, family history, social history, education, review of systems, and current medications or allergies. This part includes direct quotes from the patient or family.
Objective: This section highlights essential professional observations by the healthcare professional. These may include vital signs, laboratory tests, physical examination, imaging results, review of documentation, and other diagnostic information.
Assessment: This section encompasses all diagnoses made by the healthcare professional. It summarizes the patient’s status and progress. The section synthesizes data from subjective and objective sections to identify the primary problem (diagnosis) and different possible diagnoses (differential).
Plan: This section records the patient’s potential or discussed treatment, including the reasons for each choice. These include strategies for further assessments, treatment, referrals, follow-up, and education.
Writing a SOAP Note Step-by-Step
Even though a SOAP note offers a standardized and structured format for documenting patient information, different institutions may have preferred methods. Nevertheless, a standardized SOAP note should include the following information despite the preferred method.
Subjective
This section records information relating to the client’s personal views, experiences, or feelings. This may also include those of their close acquaintances.
Chief Complaint (CC)
Begin by recording the chief complaint (CC), sometimes referred to as the presenting problem (chest pain, back pain, cough, headache, diarrhoea, stomach pain, difficulty breathing, etc). Use the client’s own words or the person who said those words, including their relationship with the patient.
History of Present Illness (HPI)
This section includes all relevant information relating to the presented problem.
Onset – When the presenting problem started.
Location – Where the problem is located.
Duration – How long has the client had the problem?
Characterization – Patient’s description of the problem.
Alleviating or aggravating factors – What triggers or improves the problem?
Radiation – Does the problem affect different areas or the same location?
Temporal factor – Does the problem ease or worsen during a certain time of the day?
Severity – How the patient rates the problem on a scale of 1-10.
Medical History
Document information on current and past medical conditions.
Surgical History
Record information about any past surgical procedure with the date if possible.
Family History
This part includes basic information about the family.
Social History
Record information about the environment, education, occupation, eating, activities, drug use, sexuality, and suicide ideation or depression.
Review of Systems (ROS)
Include information on weight, appetite, gastrointestinal, and musculoskeletal functioning.
Medications and Allergies
Record current medications taken by the client (include the name, dose, administration, and frequency). Document all known allergies.
Objective
In this section, write about the data obtained during the interaction. This should include signs and not symptoms. Document;
- Vital signs
- Laboratory tests
- Physical examination
- X-ray results
- Review of documentation
- Other diagnostic information
- Behavior
Assessment
Diagnosis/Problem
Here, you will synthesize information from subjective and objective sections to identify the primary problem.
Note that this section will determine the treatment plan for the patient. Therefore, use professionally acquired knowledge to interpret subjective and objective information.
Differential Diagnosis
Record any other potential diagnoses and rationale. This is because some symptoms can present for different problems.
Plan
Include a detailed description of the immediate next action to address the diagnosed problem and how the steps will help achieve the desired outcomes. Write about;
- Strategies for further assessments.
- Pharmacological treatment.
- Non-pharmacological treatment.
- Referrals
- Follow-up.
- Patient education.
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