The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by health care providers to write out notes in a patient's chart, along with other common formats, such as the admission note. Documenting patient encounters in the medical record is an integral part of practice workflow starting with patient appointment scheduling, to writing out notes, to medical billing.
The SOAP note originated from the problem-oriented medical record (POMR), developed by Lawrence Weed, MD. It was initially developed for physicians, who at the time, were the only health care providers allowed to write in a medical record. Today, it is widely adopted as a communication tool between inter-disciplinary healthcare providers as a way to document a patient's progress.
SOAP notes are commonly found in electronic medical records (EMR) and are used by providers of various backgrounds. Prehospital care providers such as emergency medical technicians may use the same format to communicate patient information to emergency department clinicians. Physicians, physician assistants, nurse practitioners, respiratory therapists, pharmacists, podiatrists, chiropractors, acupuncturists, occupational therapists, physical therapists, school psychologists, speech-language pathologists, certified athletic trainers (ATC), sports therapists, among other providers use this format for the patient's initial visit and to monitor progress during follow-up care.
Video SOAP note
Components
The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.
Subjective component
Initially the patient's chief complaint, or CC. This is a very brief statement of the patient (quoted) as to the purpose of the office visit or hospitalization.
If this is the first time a physician is seeing a patient, the physician will take a history of present illness, or HPI. This describes the patient's current condition in narrative form. The history or state of experienced symptoms are recorded in the patient's own words. All information pertaining to subjective information is communicated to the healthcare provider by the patient or his/her representative. It will include all pertinent and negative symptoms under review of body systems. Pertinent medical history, surgical history, family history, and social history, along with current medications, smoking status, drug/alcohol/caffeine use, level of physical activity and allergies, are also recorded. A SAMPLE history is one method of obtaining this information from a patient.
Subsequent visits for the same problem briefly summarize the history of present illness (HPI), including pertinent testing + results, referrals, treatments, outcomes and followups.
The mnemonic below refers to the information a physician should elicit before referring to the patient's "old charts" or "old carts".
- Onset
- Location
- Duration
- CHaracter (sharp, dull, etc.)
- Alleviating/Aggravating factors
- Radiation
- Temporal pattern (every morning, all day, etc.)
- Severity
Variants on this mnemonic (more than one could be listed here) include OPQRST and LOCQSMAT:
- Location
- Onset (when and mechanism of injury--if applicable)
- Chronology (better or worse since onset, episodic, variable, constant, etc.)
- Quality (sharp, dull, etc.)
- Severity (usually a pain rating)
- Modifying factors (what aggravates/reduces the symptoms--activities, postures, drugs, etc.)
- Additional symptoms (un/related or significant symptoms to the chief complaint)
- Treatment (has the patient seen another provider for this symptom?)
Objective component
The objective section of the SOAP includes information that the healthcare provider observes or measures from the patient's current presentation, such as:
- Vital signs and measurements, such as weight.
- Findings from physical examinations, including basic systems of cardiac and respiratory, the affected systems, possible involvement of other systems, pertinent normal findings and abnormalities.
- Results from laboratory and other diagnostic tests already completed.
Assessment
A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. The assessment will also include possible and likely etiologies of the patient's problem. It is the patient's progress since the last visit, and overall progress towards the patient's goal from the physician's perspective. In a pharmacist's SOAP note, the assessment will identify what the drug related/induced problem is likely to be and the reasoning/evidence behind it. This will include etiology and risk factors, assessments of the need for therapy, current therapy, and therapy options. When used in a problem-oriented medical record (POMR), relevant problem numbers or headings are included as subheadings in the assessment.
Clinical psychologist Barbara Lichner Ingram, in her book on clinical formulation, used the word "hypothesis" in place of "assessment", resulting in the acronym SOHP instead of SOAP.
Plan
The plan is what the health care provider will do to treat the patient's concerns--such as ordering further labs, radiological work up, referrals given, procedures performed, medications given and education provided. The plan will also include goals of therapy and patient-specific drug and disease-state monitoring parameters. This should address each item of the differential diagnosis. For patients who have multiple health problems that are addressed in the SOAP note, a plan is developed for each problem and is numbered accordingly based on severity and urgency for therapy. A note of what was discussed or advised with the patient as well as timings for further review or follow-up are generally included.
Often the Assessment and Plan sections are grouped together.
Maps SOAP note
An example
A very rough example follows for a patient being reviewed following an appendectomy. This example resembles a surgical SOAP note; medical notes tend to be more detailed, especially in the subjective and objective sections.
The plan itself includes various components:
- Diagnostic component: continue to monitor labs
- Therapeutic component: advance diet
- Referrals: follow up with Cardiology within three days of discharge for stress testing as an out-patient.
- Patient education component: that is progressing well
- Disposition component: discharge to home in the morning
References
Further reading
- Baird, Brian N. (2014) [1996]. "Clinical writing, treatment records, and case notes". The internship, practicum, and field placement handbook: a guide for the helping professions (7th ed.). Boston: Pearson PLC. pp. 95-112. ISBN 9780205959655. OCLC 836261561.
- Hodges, Shannon (2016) [2011]. "Clinical writing and documentation in counseling records". The counseling practicum and internship manual: a resource for graduate counseling students (2nd ed.). Springer Publishing Company. pp. 89-114. ISBN 9780826128430. OCLC 915153123.
- Kettenbach, Ginge; Schlomer, Sarah L. (2016) [1990]. Writing patient/client notes: ensuring accuracy in documentation (5th ed.). F. A. Davis Company. ISBN 9780803638204. OCLC 934020211.
- Sames, Karen M. (2015) [2005]. "SOAP and other methods of documenting ongoing intervention". Documenting occupational therapy practice (3rd ed.). Boston: Pearson PLC. pp. 171-197. ISBN 9780133110494. OCLC 858914392.
- Weed, Lawrence L. (June 1964). "Medical records, patient care, and medical education". Irish Journal of Medical Science. 39 (6): 271-282. doi:10.1007/BF02945791. PMID 14160426. (subscription required)
Source of the article : Wikipedia
0 Comments