Download A SOAP note is a written documentation of an encounter with a

A SOAP note is a written documentation of an encounter with a patient. The
acronym stands for S: subjective, O: objective, A: assessment, and P: plan. This
method of method of accounting is used 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.
This type of notation includes the subjective component, that details the
patient’s own understanding of their complaint. This should include any
information; in the patient’s own words, about their specific problem. This portion
should include information about all pertinent and negative symptoms under
review of body systems. Pertinent medical history, surgical history, family history,
and social history, along with current medications and allergies, are also recorded.
The objective portion records the actual objective findings of the patient,
such as his or her vital signs, and any measurements that have been obtained from
the patient. This is also the area that should include anything that has been verified
by the physical examination of the patient, potentially focused on the patient’s chief
complaint. Lastly, this component should include any results from laboratory
testing.
As the note moves in to the assessment portion, one should include what the
diagnosis is as well as a list of any and all reasonable alternative possible diagnoses.
These should be listed in the record from most likely to least likely, taking in to
consideration the current state of the patient and well as their chief complaint. This
format also weighs the data that was incorporated in the objective part of the note
to help reach one of the suggested diagnoses.
Lastly, the note should have a written plan that details what the final
diagnosis is as well as what medical, physical, and pharmaceutical steps should be
taken next. This area is also an excellent place to document any advice or follow up
that has been given to the patient regarding his or her symptoms. In conclusion, this
is essentially what the healthcare professional will do to address the patient’s
concerns.
Despite seeing many patients in a day, the healthcare worker must have a
standardized form in which to record his or her impressions of the patient’s
problem. This is vital for sharing results with a patient’s home physician if they are
away or for follow up with a specialist at a later date. Furthermore, this also allows
for the healthcare team to recall what the status of the problem was at the time of
the initial visit as well as an evaluation of any follow up plans.
A SOAP note, while being critical for the care of the patient, need not be
difficult or challenging for the healthcare professional to write. Members of the
team, regardless of their ultimate role in patient care, should feel comfortable in
penning a thorough SOAP note to share with other clinicians.
An example SOAP note is provided below:
Patient Name: John Doe DOB: 11/03/1961
Record No. P-1234567
Date: 5/18/2011
S—Mild burning with frequent urination, a thin discharge that is worse in the A.M.,
irritation at the urinary opening at tip of penis, NKA.
O—Discharge with gram stain negative for gonorrhea, showing large numbers of
WBCs. Chlamydia test is positive.
A—
1. Non-Gonorrheal Urethritis
2. Allergic reaction
3. Irritation from clothing
4. Sexual abuse
P—Doxycycline 100mg BID for 10 days or Erythromycin 500mg QID for 10 days or
Tetracycline 500mg QID for 10 days. Increase fluid intake, avoid alcoholic
beverages. Pt education on safe sex practices.