It takes a bit of time to master soap notes, but it is an important equipment for documentation and communication of patient’s info. One of the most common causes of sentimental event is ineffective communication. Following this, to know how to convey information in the most accurate and clear way is the key for the clinicians to master.
In this modern time of clinical practice, the doctors need to share medical information first in an oral presentation and written progress notes, this includes physicals, histories and soap notes. Actually, SOAP is an acronym for Subjective, Objective, Assessment and Plan. These are the notes that enables the clinicians to document all the encounters of patients in a more structured manner.
So here are some detailed information about it.
What is a SOAP note?
A SOAP i.e. subjective, Objective, assessment and plan note is a way of documentation particularly used by medical providers. These notes are used by the staff to write and note all the critical information regarding patient’s health in an organized, clear, and quick manner. Once written soap notes are mostly found in the electronic medical records or patient’s chart.
How does a SOAP note work?
Here is an example to explain the functioning of SOAP notes.
A patient come inside a hospital with his/her arm swelled, but there is no idea or diagnosis for the issue yet what it could be. The physician will attend the patient and need to write a basic document in the structure of SOAP notes.
The doctor will begin with the subjective component. Note that each of the component will be different according to the patient and the stage of notes getting written. Note that, a lot of notes get written at several points until the patient gets completely rectified. Oftentimes, the subjective component includes this information;
- The age, gender and race of patient
- The CC i.e. chief complaint (in this case, the CC is arm swelling)
- The time CC happens
- The point of CC occurred in the body
- The level of CC’s severity
- Details and description about CC
- Any relevant medical history
- And such other few points
After writing down these basics, the doctor will move to the objective component of the SOAP note. In this component, the doctor needs to write what he observed from the patient, what patient is displaying and what patient has told verbally in the meeting. Also, the doctor will write down if there would be any finding of any tests that you get done priory this meeting.
These are the points that doctor needs to make sure he noted on the objective component;
- Major measurements and signs like weight, blood pressure, etc.
- Things found out after physical examination
- The final results from the diagnostic exam and laboratory
After the completion of objective component, the doctor will move to the assessment component. Here are the specific points about this section;
- The analysis of the issue
- The diagnosis of the issue potentially
- Any relevant info about the progress of the issue
The final component of the notes is the plan. In this case, the doctor need to create a post-session plan. All the plan written for any patient completely depends on the situation according to who they are, what is the issue and the stage of the issue. However, the basic points the plan includes are;
- Medication prescriptions
- Referencing to any other medical department or expert
- Additional tests that needed to get done
- Further appointments
- And anything that seems to be important
Similar to the plan, the next steps will be different according to the condition and situation of a patient. Some of the medical centers require the detailed SOAP note for review and approval by the high authority and the rest medical centers want a specific SOAP note write for uploading and completing the document to the database of all the medical records. Apart from all this, the best of all the plan action would be carried out the action tasks in the plan, the soon the better.
The benefits of SOAP notes
For sure, soap note would not have survived until now nor it would be used by various practitioners daily unless it has a lot of benefits.
So here are the benefits of using soap notes for your patient’s documentation.
- Order and organizes the way info is written
Basically, this soap note has major focus on organization and ordering. All the medical provider needs to write a lot of notes in a day. In this regard, a systemized way is ideal for the notes and documentation as it keeps everything organized and in hand.
- Note taking process gets faster
Another of its basic benefit of soap notes is that the structure it provides for writing down the notes automatically speeds up the process of documentation. This is because you do not need to write to-an-from-for while forgetting the important details. And this way you also wouldn’t have info to go back and check to add in your notes as you have forgotten to note. So it is an order already created, all you need is to stick to it and note everything quickly.
- Gives a cognitive framework for the staff
The major benefit of a SOAP note is that as you follow its method for documentation long enough then it begins to affect on the way you meet and converse with your patients. This simply means that you have well-structured and organized notes alongside the way you interact with your patient will also be organized.
- Boost up the quality of care
By writing down all the important information about the patient and its ailment, you become liable to provide your patient with the best level of care possible. This ensures you that you have reached the heart of the issue in the best possible way creating the proper plan of action.
- Helpful for Other Medical professionals
SOAP notes are mostly found in the electronic health record of patient. So if the other medical professional get access to the records of the patient they treat, SOAP notes will help them because of its well-structured, organized, and easy to read features. This will make the professional know what is exactly needed to treat the patient. It is helpful even if there is no interaction between the medical providers of that same patient.
A few current concerns with SOAP notes
Here are a few things going on about these SOAP notes.
- Acronym order
Some of the clinicians suggested to change the acronym from SOAP to APSO to quicken the ongoing care and eliminating the required time to find out the assessment and plan. Others argued that the APSO order will make the patient input less important. Maybe, it also makes the clinician less inclined for conducting more detailed examinations.
- Recording changes
Another the issue concerning the SOAP usage note is that it there is no point to record the changes over time. Often the behavioral health and addiction treatment involve difficult conditions to treat over the course of months or even years. The SOAP notes with right HER can easily make these changes to the patient’s condition, treatment and health goals.
- Inclusion of SOAP notes in EHR
The inclusion of SOAP templates in the EHR system has a great deal of benefits. Here are a few;
- High efficiency by excluding double data entry
- Auto populating data from the treatment plan section of electronic health record like diagnosis, goals and interventions
- Make it able to review the historical SOAP notes
- Incorporation of data points that end up making the golden thread
- Incorporation of data from the outcome measures
The SOAP that is subjective, objective, assessment and plan is the most commonly used system for documentation in the medical care industries today. It is highly beneficial in organizing and structuring the entire data of patients and making it work. In fact, it is effective to make changes on the way you meet up with your patients. Making use of any appropriate EHR program with SOAP notes will be the best practice any healthcare centre would ever have.