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SOAP note

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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. Prehospital care providers such as EMTs may use the same format to communicate patient information to Emergency department clinicians.

ComponentsEdit

The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. The length and focus of each component of a SOAP note varies 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 componentEdit

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. It will include all pertinent and negative symptoms under review of body systems. Pertinent Medical history, surgical history, family history, social history along with current medications and allergies are also recorded. A SAMPLE history is one method of obtaining this information from a patient.

If this is the first time a doctor is seeing a patient, they will take a History of Present Illness or HPI. To structure this portion of the note, you can use another mnemonic: OLD CHARTS[1], as in what would you find if you looked at the patient's "old chart"

Onset
Location
Duration
CHaracter (sharp, dull, etc)
Alleviating/Aggravating factors
Radiation
Temporal pattern (every morning, all day, etc)
Symptoms associated

Objective componentEdit

The objective component includes:

  • Vital signs
  • Findings from physical examinations, such as posture, bruising, and abnormalities
  • Results from laboratory tests
  • Measurements, such as age and weight of the patient.

AssessmentEdit

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. When used in a Problem Oriented Medical Record, relevant problem numbers or headings are included as subheadings in the assessment.

PlanEdit

This is what the health care provider will do to treat the patient's concerns. This should address each item of the differential diagnosis. A note of what was discussed or advised with the patient as well as timings for further review or follow-up may also be included.

Often the Assessment and Plan sections are grouped together.

An exampleEdit

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.

Surgery Service, Dr. Jones
S: No Chest Pain or Shortness of Breath. "Feeling better today." Patient reports flatus.
O: Afebrile, P 84, R 16, BP 130/82. No acute distress.
Neck no JVD, Lungs clear
Cor RRR
Abd Bowel sounds present, mild RLQ tenderness, less than yesterday. Wounds look clean.
Ext without edema
A:Patient is a 37 year old man on post-operative day 2 for laparoscopic appendectomy, recently passed flatus.
P:Recovering well. Advance diet. Continue to monitor labs. Prepare for discharge home tomorrow morning.
Note that the plan itself includes various components:
Diagnostic component - continue to monitor labs
Therapeutic component - advance diet
Patient education component - that is progressing well
Disposition component - discharge to home in the morning

CitationsEdit

Schimelpfenig, Tod (2006). NOLS Wilderness Medicine, Mechanicsburg, PA: National Outdoor Leadership School and Stackpole Books.

ReferencesEdit



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