SOAP note

SOAP Note

The SOAP note is an acronym representing a standardized method of documentation utilized by healthcare professionals for capturing notes in a patient's chart. The term "SOAP" stands for:

• Subjective
• Objective
• Assessment
• Plan

This format is integral to the medical record-keeping system and is used alongside other documentation styles like the admission note. Beyond its utility for documentation, the SOAP note format provides a structured cognitive framework for healthcare professionals to follow during patient assessments.

History

The roots of the SOAP note can be traced back to the problem-oriented medical record (POMR), an innovation developed almost half a century ago by Dr. Lawrence Weed. The POMR was designed to offer physicians a systematic approach to addressing patients with multifaceted issues. Over time, the SOAP note emerged as a key component of POMR and has since been widely adopted across various healthcare disciplines, serving as an effective tool for inter-disciplinary communication and patient progress documentation.

Components

Subjective

This section captures the patient's feelings, symptoms, and concerns. It's primarily based on the patient's verbal account.

Objective

Objective data observed or measured by the healthcare provider, such as physical examination findings, laboratory results, and vital signs, are recorded here.

Assessment

Here, the healthcare provider offers a diagnosis or a list of potential diagnoses based on the combined subjective and objective information.

Plan

This segment outlines the subsequent steps for diagnostics, therapeutics, patient education, or follow-up.

Applications

While originally crafted for physicians, the SOAP note format has been embraced by a diverse range of healthcare providers, including:

• Behavioral health specialists
• Veterinarians
• Emergency medical technicians
• And others

Moreover, with the advent of electronic medical records (EMR), the SOAP note format has been integrated as a template guiding physicians in adding details to a patient's EMR. The clear and organized structure of SOAP notes also facilitates communication in settings where patients might interact with multiple healthcare professionals, ensuring consistency and clarity in the patient's medical records.

Benefits

• Standardization: Offers a uniform format for healthcare professionals to document patient encounters.
• Interdisciplinary Communication: Serves as a universal tool for communication between various healthcare providers, ensuring continuity of care.
• Patient Progress Tracking: Assists in monitoring patient progression over successive visits.

See Also

• Electronic medical record
• Medical documentation
• Problem-oriented medical record
• Medical billing

SOAP note Resources
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