How to Make Soap Notes



Introduction: How to Make Soap Notes

SOAP is an acronym for subject, objective, assessment, and plan, and acts as a progress report for the patient and lets the healthcare providers know what has or has not been done to heal the patient. A SOAP note to the inexperienced can seem very confusing and difficult to understand. However when you break them down they become very simple. A SOAP note is by definition a document used by nurses doctors and therapist along with other health counselors. It is universally formatted so that all health care providers use the same template therefore providing clear and accurate information incase the patient switched healthcare providers.

Step 1: Formatting Your Soap Note

Most hospitals systems have their own format for writing SOAP notes between offices, but all of them begin with patients name, date of service diagnosis, and procedure code (or steps of action). Following this all SOAP notes are broken into four sections based on the soap acronym Subject, Objective, Assessment, and Plan. Most Soap notes are configured in the format in figure 3 and are available online for even more help. Most soap notes include a figure of a human body, this is present to help accurately pinpoint the patients injury and to help practitioners accurately diagnose and prescribe the correct treatment to provide the patient.   Lisa Schwartz gives the following tip on “how” to compose SOAP Notes: “Although SOAP Notes are normally short and sweet, they must also be thorough and complete.” (Schwartz) You must make sure all your information is clear and easily readable. In these instructions we will help you write an effective and properly formated soap note.

Step 2: Subject Section of the Soap Note

  The subject section of your SOAP note should be primarily about findings on the patient and observations for example “the patient looked flush today” or “the ankle was loser then usual today.” “The subject section is more or less a daily journal of your patient, which includes patient medical, drug, and family histories along with the type of illness or injury they report.” (Haley Dacks) also it is important not to forget to add your patient’s feedback to. This is extremely helpful when pinpointing their injury so you can provide the most effective care. The subject section should contain relevant information to your patient and should be quick simple and to the point if you must right in observations and patient feedback

Step 3: Objective Section of Your Soap Note

The Objective portion involves the collection of data during the physcial examination and training session. This section describes the results of the evaluation of the patient’s condition, the improvement toward stated goals, and the functional treatments involving running, lifting, etc.. Include information such as the patient’s vital signs, changes in medications, and the identification of new or previous injury.The Objective section can also contain emotional and pyschological factors such as unusual behavior or changes in mood. Incorporate the equipment used during training sessions. It is important to be accurate and concise in this section and to be cautious not to add any irrelevant information. When unnessecary information is added, confusion can occur between physicians and therapists which can result in the patient being prescribed  improper medications or receiving inadequate treatment.  As you can see, accuracy and precision is key.

Step 4: Assessment Section of Your Soap Note

 Continuing with SOAP we reach the assessment section this is the caregiver’s diagnosis of the patient. Here it is extremely important to apply your medical terminology and knowledge in this section. Figure out documentation and record your diagnosis of the patients illness or injury. Record only relevant information to the condition of the patient and any other information you deem helpful in curing and speeding up the recovery of your patient. 

Step 5: Planning Section of Your Soap Note

Lastly we reach the planning section of your soap note. In this section your will include how your diagnosis of the patient will be solved. For example what treatment you prescribed, who will be responsible for administering the treatment, when you can expect to recover, and lastly how it will be done. However this isn’t the only part of the planning section of your soap note.  You must also include a follow up and if necessary a monitoring section or in simple terms a progress report of your patient. This section can also be used for any last minute comment of concerns for the patient, I.E. “make sure to wear you leg brace to bed if you’re a rowdy sleeper.” Along with this you can also use this section to explain the goal of your therapy with your patient if you haven’t done so in the assessment section already.

Step 6: Relaying Your Information to Health Care Providers

The final step is relaying the information found throughout the SOAP process to healthcare providers. Once you have completed the SOAP Note, you must update the patient’s medical record via your offices records system and include the diagnoses and procedure codes (steps of treatment), which will assist the insurance companies in determining coverage, payment of bills and medical necessities of service. Lastly,you must  transmit the claim through electronic billing to the healthcare provider so immediate action can be taken to treat your patient and resolve their condition. 

Step 7:

REFERENCES - Step 4 - Steps 1, 2, and - Introduction - Step 1 - Step 2 - Step 3

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