What is a SOAP Note?

The SOAP Note Format

SOAP is an acronym where each letter stands for a word similarly to NASA. Just about everybody knows what NASA is, but not everybody knows what a SOAP note is.

The letters S-O-A-P stand for SUBJECTIVE, OBJECTIVE, ASSESSMENT and PLAN. Many medical offices use the SOAP note format to standardize medical evaluation entries made in patient records. The SOAP note improves communication between all caring for the patient. It displays the assessment, problems and plans in an organized format and facilitates better medical care when used.

Efficient SOAP Note Writing

Medical documentation of patient complaints and treatment must be consistent, concise and comprehensive. In your role as a medical assistant it is important that everything that needs to be documented in a patient's chart is DOCUMENTED promptly, precisely and in the right format and tone, and most importantly, in accordance with your specific medical office's rules. Always remember while documenting: the patient's medical record is a legal document, whatever is documented must be accurate and whatever wasn't documented = never happened. Under certain circumstances, an omission of vital information, or an error in the note, can become detrimental to the patient.

The SOAP note documentation should briefly express the following:

• date and purpose of the visit
• patient’s symptoms and complaints
• patient's height, weight, temperature, pulse, blood pressure, visual acuity, etc.
• new lab data and results of studies, reports, assessments
• the current formulation and plan for the patient

 

What the Medical Assistant Writes

Typical entries a medical assistant can write into the S-part (subjective observations) and O-part (objective observations) are simple phrases for the doctor, such as:

❖ Chief Complaint (CC): Patient complains of wrist pain
❖ Location (example: right hand)
❖ Quality (example: aching, burning, radiating pain)
❖ Severity (example: ache in left wrist, 5 on a scale of 1 - 10)
❖ Duration (example: started two days ago)
❖ Timing (example: constant, or comes and goes)
❖ Context (example: lifted large object at work)
❖ Modifying factors (example: better when an ice pack is applied)
❖ Associated signs and symptoms (example: numbness in ring-finger)

CONTINUE  SOAP Note Writing 

 

SOAP Note Content and Length

SOAP notes can be flexible. The content of the note will differ for each specialty and likely you will develop your own style as you try to accommodate office preferences. The note written by a novice will usually turn out to be a little longer than that of staff with more clinical judgment and experience in proper SOAP note writing format.

The SOAP note is not supposed to be as detailed as a progress report. Complete sentences are not necessary and abbreviations are appropriate, however, avoid them until you have a handle on how the abbreviations are used—often they differ for each specialty but are consistent within the medical office where you work. The hidden pitfalls of using abbreviations is that while your office may be familiar with their meaning an outside physician may not understand your abbreviations.

An inexperienced writer of a SOAP note entry will often give more thought as to what to write and wind up putting more of what they have observed to paper than is actually necessary. A short, but precise SOAP note is often better than an entry that is too verbose. As you experiment and become more proficient in your routine you will eventually develop your preferred technique to remain short and accurate. It is practice that makes perfect.

CONTINUE  SOAP Note Examples

 

• Medical Assistant SOAP Note Writing Review
  
  In your role as a medical assistant you will take vital signs, height, and weight measurements and enter it into the medical record under the "Objective" SOAP.
• Medical Assistant SOAP Note Examples
  
  SOAP note parts and how a medical assistant is allowed to enter them in a patient's record. SOAP note Example 1, SOAP note Example 2...