SOAP note
Encyclopedia
The SOAP note is a method of documentation employed by health care providers to write out notes
in a patient
's chart, along with other common formats, such as the admission note
. Documenting patient encounters in the medical record
is an integral part of practice workflow starting with patient appointment scheduling, to writing out notes, to medical billing. Prehospital care providers such as EMTs
may use the same format to communicate patient information to emergency department
clinicians.
If this is the first time a physician is seeing a patient, the physician will take a History of Present Illness, or HPI. 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. Pertinent medical history, surgical history, family history, and social history, along with current medications and allergies, are also recorded. A SAMPLE history
is one method of obtaining this information from a patient.
The mnemonic below refers to the information a doctor should elicit before referring to 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
Variants on this mnemonic (more than could be listed here) include OPQRST
and LOCQSMAT
Location
Onset (when and mechanism of injury - if applicable)
Chronology (better or worse since onset, episodic, variable, constant, etc.)
Quality (sharp, dull, etc.)
Severity (usually a pain rating)
Modifying factors (what aggravates/reduces the Sx - activities, postures, drugs, etc.)
Additional symptoms (un/related or significant symptoms to the chief complaint)
Treatment (has the patient seen another provider for this symptom?)
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.
A note of what was discussed or advised with the patient as well as timings for further review or follow-up may also be included.
Often the Assessment and Plan sections are grouped together.
Medical record
The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction....
in a patient
Patient
A patient is any recipient of healthcare services. The patient is most often ill or injured and in need of treatment by a physician, advanced practice registered nurse, veterinarian, or other health care provider....
's chart, along with other common formats, such as the admission note
Admission note
An admission note is part of a medical record that documents the patient's status, reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care...
. Documenting patient encounters in the medical record
Medical record
The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction....
is an integral part of practice workflow starting with patient appointment scheduling, to writing out notes, to medical billing. Prehospital care providers such as EMTs
Emergency medical technician
Emergency Medical Technician or Ambulance Technician are terms used in some countries to denote a healthcare provider of emergency medical services...
may use the same format to communicate patient information to emergency department
Emergency department
An emergency department , also known as accident & emergency , emergency room , emergency ward , or casualty department is a medical treatment facility specialising in acute care of patients who present without prior appointment, either by their own means or by ambulance...
clinicians.
Components
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 is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.Subjective component
Initially is the patient's Chief Complaint, or CC. This is a very brief statement of the patient as to the purpose of the office visit or hospitalization.If this is the first time a physician is seeing a patient, the physician will take a History of Present Illness, or HPI. 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. Pertinent medical history, surgical history, family history, and social history, along with current medications and allergies, are also recorded. A SAMPLE history
SAMPLE History
SAMPLE history is an mnemonic acronym to remember key questions for a person's assessment. The SAMPLE history is usually taken along with vital signs. It is used for alert people, but often much of this information can also be obtained from the family of an unresponsive person...
is one method of obtaining this information from a patient.
The mnemonic below refers to the information a doctor should elicit before referring to 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
Variants on this mnemonic (more than could be listed here) include OPQRST
Opqrst
"PQRST" is sometimes used instead.The term "OPQRST-AAA" adds "aggravating/alleviating factors", "associated symptoms", and "attributions/adaptations".-Meaning:The parts of the mnemonic are:...
and LOCQSMAT
Location
Onset (when and mechanism of injury - if applicable)
Chronology (better or worse since onset, episodic, variable, constant, etc.)
Quality (sharp, dull, etc.)
Severity (usually a pain rating)
Modifying factors (what aggravates/reduces the Sx - activities, postures, drugs, etc.)
Additional symptoms (un/related or significant symptoms to the chief complaint)
Treatment (has the patient seen another provider for this symptom?)
Objective component
The objective component includes:- Vital signs
- Findings from physical examinationPhysical examinationPhysical examination or clinical examination is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient...
s, such as posture, bruising, and abnormalities - Results from laboratory
- Measurements, such as age and weight of the patient.
Assessment
A mid-level (Nurse practitioner [NP] or Physician's Assistant [PA]) or advanced practitioner's (Physician [MD or DO]) medical diagnosis for the purpose of the medical visit on the given date of the note written.Is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis
Differential diagnosis
A differential diagnosis is a systematic diagnostic method used to identify the presence of an entity where multiple alternatives are possible , and may also refer to any of the included candidate alternatives A differential diagnosis (sometimes abbreviated DDx, ddx, DD, D/Dx, or ΔΔ) is a...
, 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.
Plan
This is what the health care provider will do to treat the patient's concerns - such as ordering labs, radiological work up, referrals given, procedures performed, medications given. This should address each item of the differential diagnosis.A note of what was discussed or advised with the patient as well as timings for further review or follow-up may also be included.
Often the Assessment and Plan sections are grouped together.
An example
A very rough example follows for a patient being reviewed following an appendectomy. This example resembles a surgical SOAP note; medical notes tend to be more detailed, especially in the subjective and objective sections.
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- The plan itself includes various components:
- Diagnostic component - continue to monitor labs
- Therapeutic component - advance diet
- Referrals - Follow up with Cardiology within three days of discharge for stress testing as an out-patient.
- Patient education component - that is progressing well
- Disposition component - discharge to home in the morning