SOAP NOTES The acronym SOAP defines four sections: (S) for subjective, (O) for objective, (A) for assessment, and (P) for plan. The SOAP note format is common to the medical setting and is used by many health care professionals. Subjective (S). The subjective section should include information given or statements made by the patient or the patient family in relation to the current deficits or ability to participate in evaluation or treatment sessions. For example, a patient who exhibits significant visual difficulty may state, I’m fine to drive a car.
This statement may be helpful to include because it provides an example of the patient level of limited insight into how her deficits may affect her performance. The subjective section is optional. If no significant remarks are made that day in the therapy session, then Objective (O): Information included in the objective section pertains to exam results, performance on therapy task, and observations made by the clinician. Assessment (A): This section of the SOAP note contains the problem list and the clinician summary of the session, including the patient performance and short-term and long-term goals.
The clinician generally makes comments on progress in this section. If there are other variable that influence the session, those may be noted in this section as well, such as a suggestion that the patient appears to be a good rehab candidate. Plan (P): this section contains recommendations and treatment approaches. Recommendations are made to the physician regarding diet changes, trach tube changes, referrals to other services, and need for follow-up therapy. Treatment plan information may include type of therapy, frequency of therapy, need for further assessment, and plans for discharge.
If there are no changes with the treatment plan, the phrase, Will cont. to follow, Can be used. Two examples of a daily progress note written in the SOAP format are shown in figure I-8 and I-9. 1. Most of the clinical work we do in medicine is Problem focused. 2. About 20 y ago Dr. Lawrence Weed developed a system of “problem oriented medical record” Charting. 3. The SOAP note is the fundamental element of the problem oriented medical record. 4. SOAP notes provide better communication among multiple providers or over multiple visits in patient care 5.
Proficiency at SOAP note charting is tested in the USMLE CS test SOAP NOTES 1. “S” Subjective: important and relevant positives and negatives from a focused hx’ 2. “O” Objective: important and relevant positive and negative physical findings, test results. 3. “A” Assessment: list of the differential diagnoses in priority of most likely or important as Determined from S and O. 4. “P” Plan: list of tests or further diagnostic work up intended to narrow, confirm or evaluate dif dx. Should include only tests or work up warranted by S and O, and should be cost Effective. SOAP cronym for subjective data, objective data, assessment, plan, the way the progress notes are organized in problem-oriented medical record keeping. SOAP Patient records a standard format for physician charting of Pt exams on a problem-based Pt record; SOAP combines patient complaints and physician determinations. See Hospital chart, Medical record. SOAP Subjective data–supplied by the Pt or family Objective data–physical examination and laboratory data Assessment–a summary of significant–if any new data, physician conclusions Plan–intended diagnostic or therapeutic action
How do I Write Nursing Soap Notes? X Jennifer Moyer Jennifer Moyer, BSN, RN, CBC, has been writing professionally since 1994. Her monthly health advice columns appear in “Ithaca Child,” “Ithaca Teen & Parent” and “Tompkins Weekly. ” She has contributed to peer-reviewed nursing journals and presentations, and is a certified breast-feeding counselor. Moyer holds a Bachelor of Arts in government from Franklin & Marshall College and a Bachelor of Science in Nursing from Columbia University. By Jennifer Moyer, eHow Contributor Know how to document a patient’s legal and medical record using SOAP notes.
A nurse writes SOAP (Subjective, Objective, Assessment, Plan) notes to document a patient’s signs and symptoms, to create a nurse diagnosis and to provide a plan of treatment. The SOAP notes are part of a patient’s medical and legal record. Nurses record all observations and interventions to provide a picture of the patient’s condition, which helps in making a diagnosis. The SOAP notes also provide a record to evaluate treatment success. Other People Are Reading * How to Write Nursing Notes in SOAP Format * How to Write a SOAP Note Things You’ll Need * Pen or pencil * Paper * Computer * Stethoscope * Lab results * Nurse X-ray * CT Scan * MRI * PET scan Show (7) More Instructions 1. * 1 Record the patient’s complaint. Record the subjective information — the “S” in SOAP — to document symptoms and complaints as reported by the patient in her own words. Include symptom examples, such as pain, vomiting and diarrhea. Document the frequency, onset, location and duration of symptoms. * 2 Take measurements and vitals, such as oxygen saturation, blood pressure and pulse to document objective information. This is the “O” in SOAP. Include measurable signs, such as lab test results, vitals, weight and height, in the objective data section.
Perform a head-to-toe clinical exam of the patient’s body’s systems to rule out various diagnoses. Document exam findings in the “O” section. * Sponsored Links * Chronic Pain Relief Stop Your Chronic Neck and Back Pain Without Surgery – Free Report www. Free-Spine-Info. com * 3 Offer a nursing diagnosis in the “A” or assessment section, which includes both subjective and objective information. Confirm and synthesize subjective and objective notes to create assessment data. Record a nursing diagnosis, such as “at risk for a sexually transmitted infection,” in this section.
Record, for example, “patient complains of shortness of breath” in the subjective section. Document “patient is wheezing in left and right upper lobes upon auscultation” in the objective section after performing a clinical exam. Record “patient is short of breath” in the assessment section as confirmation of data reported in the subjective and objective sections. * 4 Document all of the patient’s therapies and follow-up steps. Document the “P,” which is the “plan” of treatment, last. Record long and short-term treatment actions, such as “antibiotic therapy,” “follow-up X-ray in three weeks,” “patient education about
Foley catheter insertion” or “physical therapy consult. ” Include relief measures or actions that worsen the patient’s symptoms. Provide an evaluation of the success or failure of treatment interventions. * 5 Record all interventions. Document SOAP notes on the computer or in pen in the patient’s medical record per your institution’s documentation protocol. In the event of a lawsuit, SOAP notes can be used in court to provide a record of the health care team’s diagnosis and treatm Read more: How do I Write Nursing Soap Notes? | eHow. com http://www. ehow. com/how_8556058_do-write-nursing-soap-notes. html#ixzz2B2C2RvgC
