Items you will need
- Notes made during the patient encounter
- Records of measurements performed during the patient encounter
- Lab test results
- Goals for treatment
SOAP notes provide health care providers efficient and effective ways to document their subjective observations of patients they treat, objective measurements of patients' vital signs and other physical and mental characteristics, assessments of how patients have responded to previous treatments, and plans for ongoing therapy.
Include the patient's name, your name and the date and time of the encounter at the top of each SOAP note. This information is essential for filing, providing proof of care to insurers, and tracking therapeutic outcomes over time.
Jot down your initial impressions of the patient. This is the "S," or subjective, part of the SOAP note. Statements in this section of the SOAP note might read, "Sally was breathing well and said she was walking a mile each day" or "John's rash no longer showed on his face."
Record all measured patient characteristics. If you measure it, write it down. Weight, blood pressure, blood panels, physical and mental test scores, etc. and etc. get recorded in this "O"--objective--section of the SOAP note.
Evaluate the patient's status. In the Assessment section of the SOAP note, write out your opinion of what your subjective and objective observations indicate about a patient. If Jim's blood pressure has dropped 20 and 10 points from three months ago, and weight has decreased by 30 pounds, you could write, "Jim has embrace diet changes and daily exercise."
Outline next steps and ultimate goals for therapeutic outcomes. If the end goal is to clear a bacterial infection from Jane's lings but she is not responding to clindamycin monotherapy, the Plan section of the SOAP note might read, "Add quinolone."
Include other information that may be relevant to the patient's health or care. For example, if an elderly woman's husband has recently passed away, you might include a reminder to ask about the woman about her mood during her next checkup because depression can lead to poor treatment outcomes. In another example, if a man receiving between-appointment home health care visits gets a new nurse, you might want to make a note to ask him how he likes the new nurse the next time you see him.
Review previous SOAP notes before your next visit with a patient. Reviewing previous SOAP notes will improve the quality of a patient encounter and guide you in collecting patient data similar to that already recorded. Taken together, all a patient's SOAP notes should constitute a complete history of a patient's care.
Document every patient encounter. Clink on the links below to get free SOAP note templates and samples. Including very short statements and abbreviations in each section is fine, but other people must be able to interpret your shorthand. Do not be shy about sharing the contents of SOAP notes with patients. Patients will almost always appreciate knowing that you are keeping detailed records of their care and setting positive goals for them.
- U.S. General Services Administration