Do you have a SOAP Note assignment and do not know how to go about it? Relax! We understand that writing SOAP Notes can be challenging, especially if it is your first. Therefore, based on the knowledge of our best nursing writers, we have compiled a step-by-step guide to help you write one comfortably.
We begin by defining the SOAP Notes to understand what's behind the acronym. Then, the guide goes ahead to detail the importance of the SOAP notes before delving into the anatomy or structure of soap notes.
And because we always thoroughly write guides for students, exclusively based on our experience, current trends, and best practices, we have provided templates for SOAP notes for coaching, clinical, and counseling practice.
We have equally included abbreviations that you can use and tips to help you write a better SOAP Note. It does not matter if it is a case study or a hypothetical situation. As long as you have instructions, this guide will point you in the right direction.
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To begin with, the acronym SOAP stands for Subjective, Objective, Assessment, and Plan.
According to Podder et al. (2020), Subjective, Objective, Assessment, and Plan (SOAP) note is a widely used documentation method by healthcare providers. In addition, it is an approach that healthcare workers use to document patient information/records structurally and in an organized manner.
SOAP notes guide healthcare workers to use the clinical reasoning cycle to assess, diagnose, and treat patients based on objective and subjective information. They also help ease communication between health professionals, which makes intra- and inter-professional communication easier.
The SOAP notes are part of the medical records of a patient. Therefore, they need to be thorough, clear, and concise.
The father of SOAP notes is Dr. Lawrence Weed, who was a member of the University of Vermont. The use of SOAP Notes is an old practice that dates back to the 1960s.
Let's now look at how to write a SOAP note. Well, the simple four-parts medical component that gives many students headache.
Now that we know the function of the SOAP Notes let's delve into the structure of a SOAP Note in a step-by-step format.
Subjective assessment refers to the information from the patients, which helps to identify the problem.
This means that the content comes from the subjective experiences, personal views, or feelings of a patient or someone close to them.
The section offers context for the assessment and plans sections of the SOAP note.
In the inpatient setting, interim information is included here.
It is usually in narration form.
Chief Complaint (CC)
The CC or presenting problem is reported by the patient. It can be a symptom, condition, previous diagnosis, or another short statement that describes why the patient is presenting today.
The CC is similar to the title of a paper, allowing the reader to understand what the rest of the document will entail.
However, a patient may have multiple CC's, and their first complaint may not be the most significant one. Thus, physicians should encourage patients to state all their problems while paying attention to detail to discover the most compelling problem.
Identifying the main problem must occur to perform an effective and efficient diagnosis.
History of Present Illness (HPI)
The HPI begins with a simple one-line opening statement, including the patient's age, sex, and reason for the visit.
This is the section where the patient can elaborate on their chief complaint. An acronym often used to organize the HPI is termed OLDCARTS:
Clinicians need to focus on the quality and clarity of their patient's notes rather than include excessive detail.
History
Current Medications, Allergies
Current medications and allergies may be listed under the Subjective or Objective sections. However, any medication must be documented, including the medication name, dose, route, and how often.
In this section of your SOAP Note, record the objective data from the patient encounter, which includes:
Review of Systems (ROS)
This is a system-based list of questions that help uncover symptoms not otherwise mentioned by the patient.
A common mistake students make when writing the objectives section of the SOAP note is distinguishing between symptoms and signs.
Symptoms are the patient's subjective description and should be documented under the subjective heading, while a sign is an objective finding related to the associated symptom reported by the patient.
For instance, when a patient says that they have stomach pain, a symptom, it is documented under subjective. On the other hand, abdominal tenderness to palpation, which is a sign, is documented under objective.
When writing this section:
The assessment section is the working diagnosis or diagnostic impression based on your SOAP note's subjective and objective components. It means that you synthesize the information from the subjective and objective evidence to arrive at a diagnosis.
In a nutshell, the section entails assessing the patient's status through analysis of the problem, possible interaction of the problems, and changes in the status of the problems.
During follow-up visits, the section reflects the changes in Subjective and Objective as a response to time, treatment, and other interim events.
In practice, it is usually updated to accurately portray the present condition of the patient. The section can also contain the patient's risk factors, outside consultation reports, review of medication, other health concerns, and procedure/lab results.
Its main elements include:
Primary Problem/Diagnosis (Dx)/Working Diagnosis
Here, you should list the problems in order of importance. The problem, in this case, is the diagnosis.
You must list the primary diagnosis first, followed by 2-3 differential diagnoses. Also, make sure to list the ICD-10 code for the diagnoses.
Differential Diagnosis (DDx)
This part is where you list the different possible diagnoses, from most to the least likely, and the thought process behind this list. This is where the decision-making process is explained in depth.
As you list the differential diagnosis, state the rationale behind it being one. Therefore, you should cite from journals and other scholarly resources.
Besides, always cite the exact reasons based on the objective and subjective sections of the Soap notes for each diagnosis
The plan is the last part of a SOAP note. It documents the interventions for the treatment of the patient in question.
Mainly, this section presents the need for additional testing and consultation with other clinicians to address the patient's illnesses.
It also addresses any additional steps being taken to treat the patient. This section aims to help future healthcare providers understand what needs to be done next. For each problem:
NB: Look at your Bates Guide to Physical Examination for excellent examples of complete H & P and SOAP note formats.
We found a good video by Jessica Nishikawa that details the structure and function of the SOAP note for medical notes. You can use it t learn further.
Here are examples of SOAP Note templates for nursing/medical, psychology, and sociology students
Date:______________________________________________
Source of information:______________________________________________
Reliability:______________________________________________
SUBJECTIVE
Chief Complaint:______________________________________________
HPI: (Use SLIDTA)______________________________________________
Significant PMH/PSH:______________________________________________
Allergies:______________________________________________
Medications:______________________________________________
Social:______________________________________________
Smoking:______________________________________________
ETOH & Illicit drugs: (Ask If there is an area of concern & Utilize CAGE)______________________________________________
Living environment: (Ask If there is an area of concern)______________________________________________
OBJECTIVE
Vital signs______________________________________________
Recent Labs: (with a date of draw or EKG/UA/any diagnostics done that pt brings recently done)______________________________________________
General Survey:______________________________________________
Physical Exam:______________________________________________
Lung:______________________________________________
Heart:______________________________________________
(Other exams as indicated such as HEENT, abdominal...)
ASSESSMENT
Diagnosis: & ICD 10 code (Your dx is directly related to your CC/subjective/objective) include rationale & references as directed
1. (Working diagnosis)
2. Differential diagnoses
PLAN
Include references and rationale
Medications: (Bullet format)
Labs: That you are ordering
Diagnostics: That you are ordering
Referral: (To whom are you referring, reason, and how soon should they see this consult)
Patient Education: (Be specific & note if the patient agrees w/ plan or not) Include medication teaching, supportive care, when to return to work...)
Follow Up
Return to Office: (Date or time frame)
Notify office: (If s/s worsen upon completion of diagnostics)
When to seek emergency care/911
References
Session Date:
Session Time:
Session Type:
Session Location: (Skype/in-person/zoom/email/google meeting)
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Subjective: What the client said?
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Objective: What did the client do? How did the client behave?
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Assessment: What resources does the client need?
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Plan: What action steps did the client identify?
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S: I'm tired of being overlooked for promotions. I just don't know how to make them see what I can do.
O: The client positioned herself in a chair, slumped forward, and buried her face in her hands.
A: Needs ideas for better communicating her ideas with her boss; Needs ideas for how to ask for more responsibility; Needs ideas for tracking her contributions.
P: Practice Asking for What You Want scenarios; Volunteer for roles within the company that is unrelated to my current job; Brainstorm solutions to problems my employer faces.
The counseling soap note can be used by social workers, psychologists, psychiatrists, speech therapists, and students who want to write a SOAP note for speech therapy.
Example 1: Speech therapy
S: Client Y appeared alert and transitioned into the therapy room without difficulty. He was engaged and participated in all therapeutic activities that were presented.
O: Client Y produced the /r/ sound in the initial position of single words with 80% accuracy given moderate cues. (Goal Met for 2 out of 3 consecutive sessions). Besides, Client Y used personal pronouns accurately in 6/10 opportunities given minimal cues (Progressing/Goal not met)
A: Client Y continues to demonstrate steady progress towards goals in speech therapy.
P: It is recommended Johnny continue with the current treatment plan of 2 times per week for 30 minutes per session, for an estimated duration of 180 days.
Example 2: Counselling
S: They don't appreciate how hard I'm working.
O: The client did not sit down when he entered. The client is pacing with his hands clenched. Finally, the client sat and is fidgeting. The client is crumpling a sheet of paper.
A: Needs ideas for better communicating with their boss; Needs ideas for stress management.
P: Practice conflict resolution scenarios; Practice body scan technique; Go for a walk during lunch every day for one week.
Example 3: Counseling
S: I'm tired of not being considered for promotions despite working hard, committing to the growth of the company, and winning many awards.
O: The client is sitting in a chair, slumped forward, breathing hard, and burying her face in her hands.
A: Needs ideas for asking for promotion from his boss; Needs ideas for how to ask to be considered in the next promotion window; Needs ideas for tracking her contributions.
P: Come up with new innovations to issues within the company; volunteer for roles within the company unrelated to the job description; communicate with the bosses often and ask for feedback; advance education through short sources for certification; practice asking for what you want sessions.
Here is a list (not exhaustive) of the common abbreviations of medical/nursing terminologies you can use when writing a SOAP note:
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