In the world of healthcare, effective communication and documentation are important to provide high-quality care. Out of many documents, SOAP notes are one of the most vital ones.

The acronym SOAP is divided into four sections, and each section is used for a specific purpose. Subjective, objective, Assessment, and plan are used to record the condition of the patient, evaluate it, and suggest a treatment plan. It is used to document patient encounters, collect essential information, and communicate information between healthcare providers.

In this blog, we will discuss the steps that can be followed to write SOAP notes and the things that should be avoided.

Breakout of the SOAP notes

SOAP notes are broken down into these categories, each representing a specific need.

Subjective (S)

The verbal data that the patient or the caretaker’s quote. It is the symptoms that are reported by the patient or the feedback from the team.

Objectives (O)

The data that is collected are the supporting documents of the subjective data. It can be measurable or observable data. For instance, if a patient is brought to the ER with some symptoms, the reports of the test conducted or the vitals collected during the stay in the ER are captured in this section.

Assessment (A)

The key issues that are identified from all the collected data are assessed and interpreted. In the healthcare sector, the diagnosis of a condition based on the symptoms and tests are added to this section.

Planning (P)

The steps that are taken to solve the situation are noted in this section. It can be the prescribed medications, the follow-ups, or the scheduling of further tests for a clearer view will become part of this area.

Following this structure, there will be consistency and clarity in the communication and help in solving the problem.

A guide to crafting SOAP notes

Gather subjective information

Initially, when you are writing SOAP notes, you will collect the patient’s subjective experiences, personal views, and feelings. This will pave the way for the assessment and planning sections. To collect data for this section, healthcare providers should:

• Listen to the complaint and the problem reported by the patient. This can be the symptom or condition experienced by the reporter. Sometimes, these statements will help you estimate that the symptoms are not new. Rather a previous diagnosis that seeks this condition of the patient.
• Ask questions to get a clearer view. While you question, check for the severity of the conditions or the duration of the situation.
• Collect previous history, including medical conditions, surgical history, family history, and social history.
• Any allergy to the medicine or other details that the patient or caretaker wants to address.

Record the objective data

After all the subjective data, it is time for the objective data. You will focus on the findings that you have collected while examining the patient physically. These include:

• The initial vital signs include blood pressure, RBS, heart rate, saturation, and temperature.
• The notes from the physical examination include the color of the skin and eyes, respiratory function, and any abnormalities found during the examination.
• A list of all labs that need to be conducted to clear the doubts or any other diagnostic tests.
• Bringing other teams on board to recognize and review the symptoms.

Analyzing the information

The healthcare provider team analyzed the subjective and objective evidence that arrived from the diagnosis. Here, you will list the details in this order:

• Add the main problems and the diagnosis in order of importance and critical conditions.
• Making a list of other potential diagnosis in terms of being most to least likely possible.
• The reasons behind making these statements.
• The alternatives are possible but might be risky for the patients.

The treatment plan to cure the issue

Finally, you will outline the next steps and the treatment plan to cure the symptoms of the patients. These might include:

• There is a need for any further tests or consultation with another consultor for better treatment, seeing the condition and reports of the patient.
• Recommending any medications or therapy to see the visible improvements.
• I will conduct sessions with the patient and counsel if there are some psychological conditions addressed.
• Advising a proper dietary plan to stay healthy and the items to avoid any allergic reaction.

The things that should be taken care of when writing SOAP

Some common mistakes are being observed in the written SOAP notes. Avoid those for better efficiency.

Don’t overload the subjective section

Don’t overfill the subjective section with so much information that might not be important. Just try to stay focused on the information that might be aligned with the symptoms reported.

Enough measurable data

To make sure that the objective data is measurable, support it with numbers, observations, or graphs.

No complex language

When a patient is in the ER bed or the hospital, the notes you make will be used by others. Try to keep it concise and the language used should be read-friendly. Each point is linked with the previous point for actionable insights. Don’t use generic statements. Your notes should give a professional look.

No vague plans

All the plans suggested should be detailed. Disclose the ways you will execute the tasks, deadlines, and the things that will be achieved.

FAQs

What does the acronym SOAP refer to?

The SOAP notes By Nursing Essays are categorized into four stages: Subjective, objective, assessment, and planning stages.

What makes the SOAP notes unprofessional?

Your written note should use a professional tone. It should avoid overly wordy phrases and biases in the sense of being positive or negative. Stay focused on what you want to convey concisely and support all your statements with evidence.

Why are SOAP notes important?

These notes make sure that all the information related to the health of the patient is recorded. Then, healthcare advisors can take a step and make decisions regarding the treatment.

When are SOAP notes helpful?

When you want detailed notes of the progress, the case is complex, or in multidisciplinary settings, the SOAP notes play a vital role.

The final comment

SOAP notes are an important tool in the healthcare sector that helps with effective clinical documentation and communication.

Following the steps stated and incorporating the correct information, accurate SOAP notes can be maintained. Remember, the things that you should avoid that can turn your notes into an unprofessional look.