While at clinical rounds in a Medical school, you might need to document information related to patients in order to, later on, discuss with your team or your seniors. The team might include nurses, attending physicians or even your seniors and while discussing you would definitely want the presentation to convey a clear idea of what is going on with the patient. If your document isn’t organized and proper, that can lead to misunderstandings which may even prove to be futile and even at times risky.
In order to avoid this, Larry Weed theorized SOAP, a standard method for providing patient information, almost 50 years ago. The best thing about SOAP note is that it helps guide healthcare workers to use their clinical reasoning in order to assess, diagnose, and treat a patient effectively, based on the information provided. These notes are a vital piece of information focussing on the health status of the patient and serve as a communication document between health professionals as well.
SOAP, Subjective, Objective, Assessment and Plan, has now become the most widely used method for structural and organized documentation.
SOAP Notes Format
The SOAP Notes have 4 different headings explained below:
The SOAP notes start with the subjective statements of patients or their close ones. It’s considered to be patient feedback by the experts, hence called subjective as there is no real method to verify or measure if they are right or not. They aren’t facts but can be used to uncover solid facts. This section provides context for the last 2 sections: Assessment and Plan.
Since there are a bunch of things you have to write about in this section, remember the mnemonic OLDCHARTS - each letter stands for a question to consider when documenting symptoms.
Here you can write the first time the patient noticed symptoms. Once you know the onset of the symptoms you can establish a timeline to find the source of the problem.
Note the area of the body where the patient feels pain or the location of the symptoms.
How long has the patient experienced the symptom or the pain?
It refers to the type of pain, whether it is stabbing, dull, throbbing or aching. It’s another critical factor you must include in your notes.
In some cases, patients might notice upon doing some particular things the pain reduces and anything that improves the symptoms is called an alleviating factor. You need to ask your patient if the symptoms improve when they maybe sit down or stand up or if anything makes it worse.
Ask the patient if the pain radiates? While some symptoms remain isolated to particular areas, others may radiate over time. This can tell you a lot about the source and eventually help in treating the condition.
Make a note of whether the said symptoms have a set pattern, such as occurring every evening or morning. Ask them if they notice any particular patterns. This can help you craft a viable treatment plan.
Ask your patients about any secondary symptoms or pain that might be present.
This section involves objective observations, the symptoms you can see, measure, hear or feel, like pulse, blood pressure, respiration, swelling, discoloration, cuts or anything else.
- Vital signs
- Physical exam findings
- Laboratory data
- Imaging results
- Reviewing documentation of other clinicians.
Once you’ve listed the above 2 sections clearly, you can now go ahead and diagnose the condition the patient has or might have. Sometimes there can be one clear diagnosis while at times a patient may have several things wrong. While assessing a patient, the health care professional refers to notes taken in the objective and subjective and based on them assess the situation of the patient. Assessments might change when you get new information.
In some cases, it might be easy to diagnose the condition of the patient, while in others it can be difficult because of several symptoms.
Once you’ve all the information in place, you can go ahead and create a plan of action for your patient. In some cases, the plan will be prescribed medication or treatment, in others, it can be asking them for additional tests to get a clearer picture of the patient’s health.
The most important thing in the entire process will be communicating with your patients during the planning stage. Don’t make that mistake. Make sure you keep your patients in the loop about their treatment. This will give them peace of mind and reduce any fear they might have.