A vehicle mechanic uses a log to maintain the data while a health worker maintains a soap note to update the record and communicate with other colleagues. If you are working presently at a hospital, you must have heard that your fellow colleagues are writing soap notes to record patient information and decide further steps.
Have you become curious about what SOAP is all about? Let us unleash the tenets of soap notes in this article and also list a range of examples that you can apply in the health care environment based on your role.
SOAP notes – what is it?
We did list a few soap notes examples above for you to gain an overview of what we are about to discuss. SOAP is an acronym that can be expanded as a subjective, objective, assessment, and plan.
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Subjective denotes all information related to the patient such as history, issue, problem, and proposed clinical intervention. On the other hand, objective denotes the observations of health professionals and the interventions appropriate to achieve the mission for the betterment of that patient.
When does an intervention prove to be successful? It is when the assessment yields positive results. For example, the patient outcomes and the chosen intervention are compared by the top management to identify discrepancies and sort with radical solutions. Followed by assessment, it is essential to plan the intervention to fulfill the objectives initially decided by the involved parties.
It is not mandatory to write the acronym but it is crucial to follow this order in patient notes so that it becomes easier for the third party to understand and propose an intervention plan accordingly.
Soap note examples for therapists
When a patient transitions from one therapist to the other either for a second opinion or for a change in the intervention. In such cases, the new therapist goes through the SOAP prepared by the previous therapist to arrive at suitable conclusions. This is a structured method used to gain information about the patient and his/her medical illnesses over a specific period. Whether you are an occupational therapist or a surgeon or a psychiatrist, the medical field does not matter but it is the widespread usage of SOAP that keeps your work constructive and much organized.
If you are new to a SOAP note or just beginning your practice, you can take a look at a few printable templates listed below.
You would have noticed several things in the examples listed.
- These notes allow you to make better decisions to maximize subjective clinical outcomes for a patient.
- It is possible to structure the treatment plan information for the patient so there is a cooperation between the patient and the therapist.
- Every initiative of yours to address the health care need of the patient is recorded. As a result, the quality of care is quickly evaluated along with your skills and expertise.
- Writing and using an information notes stands as an excellent proof of evidence to tell others that you have consistently taken attempts to cure the patient and the patient has shown varied results at different points. Your expertise passes in the legacy despite the dissatisfaction of the patient or lack of cooperation exhibited by the patient’s family during the treatment period.
- You can use it on the go instead of carrying a number of files and X-ray copies. This is just one comprehensive document that connects the pin to plane about the patient’s health.
Soap notes for nurse practitioners
Similar to the therapist, it is the responsibility of nurse practitioners to apply clinical skills and maximize the quality of care with substantial evidence. There are several instances when therapists do not have enough time to record the treatment plan and share it with you. You are liable to fill the SOAP note with the appropriate information as it is used at a later stage when crucial decisions need to be taken.
As a novice in SOAP notes, it gets difficult to complete it accurately. However, we are here to help you!
The first component is subjective. In this objective section, you need to fill the medical history of illness (including date), other symptoms, affected parts of the body and past treatment. Finding it too long to remember? Remember the OLD CHART mnemonic that stands for onset, location, duration, character, alleviating aspects, radiation, temporal patterns, and severity. This gives a complete background of the patient’s health condition and lets you review the systems used in the past to determine the effectiveness and inform the therapist. You can add new fields like supporting symptoms if you find that these can add the quality of patient care.
Following subjective component, make notes of vital signs, pain, therapy, results of physical examination and laboratory results in the objective component notes section you are using. No doctor can go through piles of paper to understand the reaction and condition of the patient. You can keep it short by developing findings, statements, and observations. It is essential for subjective and objective components to match with each other’s section.
In the assessment component, make a note of initial differential diagnosis, the purpose of visit, findings, progress, and drug-related problems. These are just sufficient for the physician to plan further. If the patient has been visiting for long-term treatment, you may just note down the progress. This is sufficient to find out what has worked and what has not.
The last component which is central to the patient’s outcomes is the plan. What is the physician going to do next? List the plan along with the goals of this treatment. Update the components listed above as and when you find a change in the results. This is an iterative note that helps patients as well as caregivers.
Aren’t these practical enough to quickly fill and add ease to your role as a nurse practitioner? Unlike other tools that enhance your screen time and demand you to learn new processes, SOAP notes is the way too easier and effective as well.
Soap notes examples for social workers – medical documentation
The last set of medical method of documentation examples that we have in hand is for social workers. These are volunteers that are responsible to collect the data and assist the decision-makers in the healthcare institution. When all the nurses are occupied due to an environmental crisis, social workers are engaged to collect info and direct them to appropriate healthcare departments.
If you work in the emergency response division or a social worker wishing to know about this technique, go through the examples listed below.
Chief Complaint/Mistakes to avoid in objective SOAP notes information
It is evident that an objective information SOAP notes is a traditional tool that is comprehensive and easier for professionals to record data and make decisions. Consequently, it is time-consuming and the terms may sound complex for a layman to understand it immediately for using. There are certain mistakes to avoid so that this tool appears productive and helpful.
- In the absence of supporting evidence, NEVER include statements based on your thoughts.
- General statements are unhealthy and should be avoided to include.
- Do not focus on qualitative info. Instead, one should concentrate on quantitative information section that can maximize the accuracy of your note.
- Remember that every component has an individual purpose. Assessment is usually copied from previous sections which is a grave mistake. This component intends to record the regression or progression of the patient’s health.
- NEVER assume the outcomes of the patient. For instance, writing a blind statement that the patient is recovering well may impact the decisions taken by the healthcare professional.
- It is acceptable to adjust objective cues but not include extra information that may confuse the end results.
- NEVER give suggestions of prevention techniques in SOAP notes. Though you may slightly customize by adding a separate subtopic in the end, prevention is not the goal of this tool.
- Avoid sentences. Instead, keep it crisp!
While we did tell you the mistakes to avoid, you have a considerable degree of flexibility with the plan component of the SOAP notes. You may extend it by including sub-components like diagnostic, therapeutic, referrals, patient education, and disposition. This is useful to include especially for patients taking long-term treatment. It is easy to follow up with one comprehensive document in hand instead of heaps of files that require sorting and are time-consuming.
The SOAP is the simplest technique available for healthcare professionals and other stakeholders/providers to practice to maximize patient outcomes. As you complete writing the note for your patient with our SOAP format for download, it is feasible to measure the degree of care and the quality of treatment you provided as providers along with the areas where you need to improve yourself as a professional.
Alternatively, every patient needs to know what the physician has done and these SOAP note are enough to guide you to start with this tool. Get well in your career as your patients get well with your treatment! May this year be as productive as this tool going forward!