SOAP notes are one type of note documenting clinical care used in health clinical settings. Different health care institutions use SOAP notes variations.
How to Write a SOAP Note
SOAP is an acronym for Subjective data, Objective data, Assessment and Plan for treatment. SOAP note has to be brief, informative, focus on what others need to know (e.g., doctors, nurses, etc.)
How to Write a SOAP Note: SOAP notes are the most popular format in medical settings and consist of information presented in the following order:
-Subjective
-Objective
-Assessment
-Plan
Subjective: Includes information you have learned from the patient or people caring for the patient (if the patient is unable to speak for himself or herself). Chief complaint, when, where and how pain/injury began. Always remember to ask about: nausea, vomiting, headache. Include age, gender, race. This part of your notation should describe your impressions of the patient, as well.
Objective: This section includes visual and palpable observations and measurements that you have made during the physical examination. Includes the vital signs, a general description of the patient, Head to Toe Exam, results of diagnostic testing, laboratory results, family history, past medical history.
Assessment: What do you feel is the patient’s differential diagnosis and why? Include whether the condition is acute or chronic.
Plan: The Plan of action is a final section of your SOAP notes where you outline the course of treatment, after considering the information you gathered during the session (medication ordered, therapy, patient disposition)
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