The How-To for Soap Note Writing
The SOAP note is a document in the medical sphere, which contains all details of a patient’s medication. The title means Subjective, Objective, Assessment, and Plans. It is very important to control the accuracy of adequate treatment and in several situations to confirm the patient has got proper drugs and services. Its main goal is to help in standardization for medical cases.
Description of SOAP Elements
There are 4 main parts of this document according to its title: Subjective, Objective, Assessment, and Plans. Here are the meanings of each paragraph:
- Subjective is a text written according to oral information provided by the patient. He explains his problem, symptoms, feelings, etc.;
- The objective includes the scientific researches and observation of his problem. Here should be all information that can help to investigate the reasons for disease and prescribe proper treatment;
- Assessment is a part of the different concepts of the patient. In addition, there must be the results of consultation with therapist according to previous findings in patient’s analyses and medical research;
- Plans mean the final actions for the patient to make him recover. Thanks to such a prescription, he will become healthy as soon as possible.
Origin of SOAP
The first notes about SOAP belong to 1960s. Exactly at that time, Dr. Lawrence Weed, who was a member of the University of Vermont, created the first SOAP document. During his professional experience, Dr. Lawrence always said that his invention must be very helpful in the problem-oriented medical record. And frankly speaking, this statement is absolutely true.
All medical specialists will agree that SOAP notes are vitally important for all kinds of medical institutions. Besides, they usually have the template to help all colleagues to organize medical information for their sake. Besides, other establishments with another type of SOAP note may have difficulties with identifying the data in such documents.
It means that nevertheless impressive usage of SOAP notes, the medical staff may have both advantages and disadvantages. Let’s take a look and determine all the pros and cons of using SOAP.
Advantages of SOAP Notes
So such a job with SOAP notes brings lots of advantages for medical officers and patients. Its main goal is to make a uniform way to collect and organize all medical information of every single patient. Besides, this document helps not only to find the proper way of medical records’ standardization but also allows understanding the patient’s needs and most proper treatment for his case.
Besides, the SOAP note is written using a special language so-called medical terms and abbreviations. Such an approach allows making the general base of words to improve the communications between medical officers. They can do it in the quickest and clearest manner.
Disadvantages of SOAP Notes
It is said such document usually includes numerous abbreviations. Medical workers are professionals and understand most of such terms. But people without medical knowledge or even education will have no opportunity to use it. But understand it is okay for such specific writing.
Doctors in physiotherapy tent to consider this document to be very poor and limited. They insist that there are no full how-to for making SOAP notes more functional. Such an issue sometimes means more serious problems with reaching functional tasks.
But let’s be honest with each other in this situation. The SOAP notes include only 4 elements to make sense. If we try to increase its length and tasks, we will get a quite complicated file with numerous issues in its understanding. In any case, you can find out more about how to create a SOAP if you need it. Here is the professional guidance in making such text.
How to Prepare a SOAP Note
Now you know that medical documents are very important for doctors, patients, and other people in and outside this field. When you need health care, you require the best services, and the SOAP notes will be a part of its improvement. But due to numerous reasons, we can still face situations of ignoring SOAP rules. If we expect to make our best in the medical sphere, we have no right to miss any important detail. That’s why writing such document has minimum requirements to set staff free from the annoying job. Let’s hope it will help to support the role of SOAP notes.
There is no requirement in length and other things in writing SOAP texts. The content is much important for medical workers and patients than in the format. That’s why the first task for a writer is to control the quality of the text. Mistakes and misprints are not allowed. In any commercial or academic writing, even one mistake can ruin the general impression from content and cause serious problems. When it goes about writing SOAP notes, you are holding someone else’s life in your hands. So be attentive and professional in your writing.
Thanks to recommendations of the American Physical Therapy Association, we have exact guidance of the SOAP notes content. It should include the following data:
- the full self-report of your patient (he must express all feeling and symptoms of current condition);
- the description of all interventions;
- the details of the equipment which was previously used;
- the response of your patient on each stage of medical research and treatment;
- the full descriptions of all issues, negative reactions, feelings, and complications (including patient’s complaint);
- main reasons why the intervention was changed;
- the list of reached goals;
- the details of communication (to estimate its quality for the future).
As a professional medical officer, you must remember that your SOAP notes may someday be used by another doctor. For example, when you are still holding the case of this patient, you may require other specialists’ consultations. Or when your patient had already recovered and is going to require medical care in the future. Such factors make you ensure yourself that you properly write your SOAP notes and do not let any mistake to happen.
In the previous paragraphs, we have already shortly described the main elements of SOAP notes. Let’s have an in-depth look in writing the Subjective, Objective, Assessment, and Plans. This guide will help you make informative text.
How to Write a Subjective Part
Writing this part starts with a close conversation with your patient. He must speak, and your task is to note. Let him share all feelings, problems, symptoms, and family history. Each thing may be important in the diagnostic field. Besides, sometimes not only patient participates in such conversation, but also his or her family members.
In your text, you can use abbreviations or direct quotes. The main goal is to document the patient’s impressions of his condition. That’s why you can use suggestive questions to help him share each detail. But try to avoid closed questions which can give you a short answer ‘yes’ or ‘no’. Such a conversation will be uninformative. Also, try not to judge the patient because he may be a little wiggly because of his feelings.
Here are the main parts of your Subjective paragraph:
- the complaint;
- the painful feelings;
- description of how he got injury;
- the anamnesis (medical history of a patient).
The Subjective part of SOAP notes is very important. It allows the doctor to make further conclusions.
How to Write an Objective Part
This part requires the writer to share all details from the medical side. It includes such tools as frequency, duration, amount, and used instrument. Also, notice in your SOAP note all kinds of patient’s reactions to the mentioned above methods.
The Objective block usually consists of such elements: vision, circulation, range of motion, palpation, muscular test, additional experiments. Be very attentive to all reactions and actions while examining your patient.
Also, remember the following rules:
- Highlight all special tests if you use them;
- Identify the possible injury to have more options on the next stage;
- Get as more details from your medical tools as you can;
- Prefer exact type of motion (active, passive, etc.) instead of general types.
How to write an Assessment Part
This part includes the professional point of view and final thoughts of the medical expert. He must share his ideas according to all findings which were gathered before. Besides clear conclusion, the doctor must explain why he makes such a conclusion, it means that all interventions must be based on rational facts and evidence.
Besides writing an assessment, the writer must forecast negative consequences, terms of treatment. The positive response must also be there. Here is further information in making Assessment:
- Give the full description of each issue;
- Avoid general phrases which can twist your Plans and SOAP notes in general;
- Never make vague conclusions.
After you are finished with your Assessment, you must keep writing SOAP note with the final paragraph called Plans.
How to Write Plans
As you have already understood, this is no unimportant part of SOAP notes. But Plans has much more meaning because it is the last element in the document. This part of SOAP is dedicated to the patient’s treatment, which may be described in different kinds from medication to urgent surgery.
The doctor is obligated to include in the Plans, both short-term and long-term recommendations. For instance, short-term advice is to take pills. This is one of the most spread ways of treatment. Among the long-term analysis, you can find changing the lifestyle, etc. In addition, you can to the Plan block the expected results. It may be helpful for the future to analyze the advantages of exact treatment.
To make the best Plans for SOAP notes, you should also remember:
- Your pieces of advice in the plan must be a daily basis;
- You are not allowed to give only general recommendations;
- Make sure that the upcoming plan is also added.
The Best Tips in Making SOAP Note
There is lots of information about the meaning and writing such documents. Try to use the following recommendations if you aspire to make the most informative:
- Make your SOAP notes simple and easy-to-understand. Remember that not only you but also other people should have an opportunity to read and use its information;
- Write your text straight according to the well-known sample in the medical field. Such an approach helps to keep the proper structure, tone of voice, and other standardized elements of notes;
- Add only fair and relevant information about the patient’s treatment. This is a golden rule which has no exceptions;
- Use only those word combinations and abbreviations which are proper for medical workers. It is a professional and humanistic way to do your job;
- Fill information right after you get it and never miss an important detail. Don’t postpone your writing so you will describe your case fully and responsibly.
Besides such recommendations remember these additional notes. You should always keep your writing away from:
- Using fake data about the patient and his treatment.
- Using terms and word combinations which are not relevant to well-known medical vocabulary.
- Include undefined and vague information.
- Make SOAP too long or too short.
- Infringe previously accepted SOAP note template.
Use the following help and create high-quality documents in the medical sphere! If you need any help, you can ask Tutoriage for a consultation. Feel free to get professional support in SOAP notes writing.
Example of a SOAP Note
To start writing the best SOAP, the author should see several good examples. We recommend you to get real notes and analyze them according to your experience before making your own text. You can also ask your teacher to give your SOAP notes with mistakes so you can find and fix them. Such homework will be best to check your knowledge and skills in making SOAP documents.
In any case, such close acquaintance with SOAP notes will help you to improve your medical and writing skills. Save this article and share it with your colleagues to make a general contribution to health care department development.
So SOAP is professional writing among medical specialists since the 1960s. This document has much more advantages and several small disadvantages, but the medical sphere does really require it. Both patients and doctors will get only benefits from such professional text.