What is an episodic SOAP Note?

What are SOAP Notes?

While SOAP notes can be difficult to understand, they can prove useful in documenting and communicating patient information.

Journal of Patient Safety reported that ineffective communication was “one of the leading causes of sendinel events.” These are dire consequences. These are dire consequences for doctors in training. They must communicate medical information clearly, concisely, and accurately.

Modern clinical practice allows doctors and nurses to share medical information through oral presentations, written progress notes (which can include physicals and histories), and written notes. SOAP, or subjective-objective, assessment plan, and note, allows clinicians to keep track of patient encounters in a structured way.

What is a SOAP Note exactly? This guideline will show you how to create progress notes.

Subjective

Begin your SOAP note by taking the information you have gathered directly from your patient. Do not interpret or create your own conclusions. These should be included:

1. This is the main complaint of the patient.

2. To standardize your reporting across all notes, use the acronym OPQRST

• The onset symptoms for the patient.
• Any provoking, or palliating factor.
• Quality refers to the symptoms of the patient.
• The area that is affected by the symptom.
• The severity along with other symptoms.
• The time course to treat the patient’s symptoms.

3. Relevant medical history, including the patients:

• Previous medical and surgical history.
• Family history
• Social history.

4. A current list of all medication in the patient’s possession with information about dosages and frequency.

Objective

The objective section of your SOAP note should include, as you would hope, objective information you have gathered through patient encounters.

1. Start by checking the patient’s vitals.

2. The physical exam will be next. Begin by taking a general impression. Next, examine your ears, nose, and throat. Any other relevant exams should be included.

3. Any other diagnostics results, such as the following:

• Laboratory tests include complete blood count, liver function, and basic metabolic panels.
• Imaging includes X-rays and Computed Tomography scans.
• Additional diagnostic information such as electrocardiograms.

Assessment

Submit your assessment once you have completed the objective and subjective sections.

1. In one to two sentences, a summary of the patient’s past should include their age, major diagnosis, and clinical stability. Example: Mrs. K was an 85-year-old woman suffering from dysuria, fatigue, and secondary urinary tract infections. She is now clinically stable and has switched to oral antibiotics from intravenous antibiotics. The summary should include multiple major diagnoses.

2. If your patient has any new symptoms, you should include a differential diagnosis.

Plan

Include your SOAP note in your plan.

1. To organize your problems, make a list of all patients’ medical issues.

2. A plan should be created for how you will handle the problems.

3. Care for an inpatient by taking note of their deep vein prophylaxis code status and disposition.

As with any skill, practice makes perfect. Take SOAP notes as an opportunity to learn. You can become proficient in drafting important medical communications if you put in enough effort.

Template for Clinical SOAP Note Format

Subjective – The “history” section
HPI: include symptom dimensions, chronological narrative of patient’s complaints,
information obtained from other sources (always identify the source if not the patient).

Pertinent past medical history.

Pertinent review of systems, for example, “Patient has not had any stiffness or loss
of motion of other joints.”

Current medications (list with daily dosages).
Objective – The physical exam and laboratory data section

Vital signs include oxygen saturation when indicated.

Focuses on physical exam.

All pertinent labs, x-rays, etc. are completed at the visit.

Assessment/Problem List – Your assessment of the patient’s problems

Assessment: A one-sentence description of the patient and major problem

Problem list: A numerical list of problems identified

All listed problems need to be supported by findings in subjective and objective areas
above. Try to take the assessment of the major problem to the highest level of
diagnosis that you can, for example, “low back sprain caused by radiculitis involving
left 5th LS nerve root.”

Provide at least 2 differential diagnoses for the major new problem identified in your
note.
Plan – Your plan for the patient is based on the problems you’ve identified

Develop a diagnostic and treatment plan for each differential diagnosis.

Your diagnostic plan may include tests, procedures, other laboratory studies,
consultations, etc.

Your treatment plan should include patient education, pharmacotherapy if any,
other therapeutic procedures. You must also address plans for follow-up (next
scheduled visit, etc.).

Also, see your Bates Guide to Physical Examination for excellent examples of