Physician SOAP Notes

What Does SOAP Stand For?

1. SUBJECTIVE — The initial portion of the SOAP note format consists of subjective observations. These are symptoms the patient verbally expresses or as stated by a significant other. These subjective observations include the patient's descriptions of pain or discomfort, the presence of nausea or dizziness, when the problem first started, and a multitude of other descriptions of dysfunction, discomfort, or illness the patient describes.

2. OBJECTIVE — The next part of the format is the objective observation. These objective observations include symptoms that can actually be measured, seen, heard, touched, felt, or smelled. Included in objective observations are vital signs such as temperature, pulse, respiration, skin color, swelling and the results of diagnostic tests.

3. ASSESSMENT — Assessment follows the objective observations. Assessment is the diagnosis of the patient's condition. In some cases the diagnosis may be clear, such as a contusion. However, an assessment may not be clear and could include several diagnosis possibilities.

4. PLAN — The last part of the SOAP note is the health care provider's plan. The plan may include laboratory and/or radiological tests ordered for the patient, medications ordered, treatments performed (e.g., minor surgery procedure), patient referrals (sending patient to a specialist), patient disposition (e.g., home care, bed rest, short-term, long-term disability, days excused from work, admission to hospital), patient directions (e.g. elevate foot, RTO 1 week), and follow-up directions for the patient.

What IS a SOAP Note?

The SOAP note format is used to standardize medical evaluation entries made in clinical records. The SOAP note is written to facilitate improved communication among all involved in caring for the patient and to display the assessment, problems and plans in an organized format. Many Electronic Health Records (EHR) systems are capable of producing SOAP Notes. The actual notes and other information contained within the EMR are commonly referred to as Electronic Medical Records or EMRs. Here's more information on EHRs

Components of a SOAP Note?

The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. The length and focus of each component of a SOAP note varies depending on the specialty; for instance, a surgical SOAP note will generally be much briefer than a psychiatric SOAP note, and will focus on issues that relate to post-surgical status.

Subjective component

This describes the patient's current condition in narrative form. The history or state of experienced symptoms are recorded in the patient's own words.
It will include all pertinent and negative symptoms under review of body systems in addition pertinent medical history, surgical history, family history, social history along with current medications and allergies are also recorded.
A SAMPLE history is one method of obtaining this information from a patient.
If this is the first time a doctor is seeing a patient, they will take a History of Present Illness or HPI. To structure this portion of the note, you can use another mnemonic: OLD CHARTS, as in what would you find if you looked at the patient's "old chart"

• Onset
• Location
• Duration
• CHaracter (sharp, dull, etc)
• Alleviating/Aggravating factors
• Radiation
• Temporal pattern (every morning, all day, etc)
• Symptoms associated

Objective component

The objective component includes:

• Vital signs
• Findings from physical examinations, such as posture, bruising, and abnormalities
• Results from laboratory tests
• Measurements, such as age and weight of the patient.

Assessment

Is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. When used in a Problem Oriented Medical Record, relevant problem numbers or headings are included as subheadings in the assessment.            

What is a Problem Oriented Medical Record

A Problem Oriented Medical Record (POMR), a method of recording data about the health status of a patient in a problem-solving system. The POMR preserves the data in an easily accessible way that encourages ongoing assessment and revision of the health care plan by all members of the health care team.
The particular format of the system used varies from setting to setting, but the components of the method are similar. A data base is collected before beginning the process of identifying the patient's problems. The data base consists of all information available that contributes to this end, such as that collected in an interview with the patient and family or others, that from a health assessment or physical examination of the patient, and that from various laboratory and radiologic tests.
It is recommended that the data base be as complete as possible, limited only by potential hazard, pain or discomfort to the patient, or excessive assumed expense of the diagnostic procedure. The interview, augmented by prior records, provides the patient's history, including the reason for contact; an identifying statement that is a descriptive profile of the person; a family illness history; a history of the current illness; a history of past illness; an account of the patient's current health practices; and a review of systems.
The physical examination or health assessment makes up the second major part of the data base. The extent and depth of the examination vary from setting to setting and depend on the services offered and the condition of the patient.
The next section of the POMR is the master problem list.
The formulation of the problems on the list is similar to the assessment phase of the nursing process. Each problem as identified represents a conclusion or a decision resulting from examination, investigation, and analysis of the data base. A problem is defined as anything that causes concern to the patient or to the caregiver, including physical abnormalities, psychologic disturbance, and socioeconomic problems. The master problem list usually includes active, inactive, temporary, and potential problems. The list serves as an index to the rest of the record and is arranged in five columns: a chronologic list of problems, the date of each problem's onset, the action taken, the outcome (often its resolution), and the date of the outcome. Problems may be added, and intervention or plans for intervention may be changed; thus the status of each problem is available for the information of all members of the various professions involved in caring for the patient.
The third major section of the POMR is the initial plan, in which each separate problem is named and described, usually on the progress note in a SOAP format: S, subjective data from the patient's point of view; O, the objective data acquired by inspection, percussion, auscultation, and palpation and from laboratory and radiologic tests; A, assessment of the problem that is an analysis of the subjective and objective data; and P, the plan, including further diagnostic work, therapy, and education or counseling. After an initial plan for each problem is formulated and recorded, the problems are followed in the progress notes by narrative notes in the SOAP format or by flow sheets showing the significant data in a tabular manner.
A discharge summary is formulated and written, relating the overall assessment of progress during treatment and the plans for follow-up or referral. The summary allows a review of all the problems initially identified and encourages continuity of care for the patient.