How to write a SOAP note

Writing a SOAP note is a critical skill for healthcare providers, ensuring accurate and thorough documentation of patient encounters. This article offers a step-by-step guide, practical examples, and customizable templates to help you master this essential task.

By addressing common challenges such as completeness and accuracy, you'll learn how to create an effective SOAP note that enhances patient care and streamlines communication among healthcare teams.

Whether you're a beginner or an experienced professional looking to refine your skills, this guide provides valuable insights and practical tools to improve your documentation practices.

What's A SOAP Note?

A SOAP note is a structured way for healthcare providers to document patient encounters in their medical records and keep track of their pertinent medical history. SOAP notes promote clear communication and ensure all relevant information is recorded for future reference by other healthcare facilities involved in the patient's care. They also serve as a tool to track a patient's progress over time, especially if the patient has a problem-oriented medical record.

What Is Included In A SOAP Note?

Here's what each section of a SOAP note typically includes:

Subjective:

• Patient's chief complaint: The main reason for the patient's visit or the primary concern they have.
• History of present illness (HPI): A detailed narrative of the patient's symptoms, their onset, duration, severity, and any factors that aggravate or alleviate them.
• Past medical history: Information about the patient's past medical conditions, surgeries, and significant health events.
• Medications: A list of current medications the patient is taking, including dosages and frequencies.
• Allergies: Any known allergies to medications, foods, or environmental factors.
• Social history: Information about the patient's lifestyle, including habits such as smoking, alcohol use, and exercise.
• Family history: Details about the health conditions of the patient's immediate family members.

Objective:

• Vital signs: Measurements such as blood pressure, heart rate, respiratory rate, temperature, and sometimes oxygen saturation.
• Physical examination: Findings from the examination of various body systems, including general appearance, specific organ systems (e.g., cardiovascular, respiratory), and any abnormalities noted.
• Laboratory data: Results of diagnostic tests such as blood tests, imaging studies (like X-rays or MRIs), and other relevant investigations.

Assessment:

• Diagnosis: A statement of the healthcare provider's assessment or diagnosis based on the subjective and objective information gathered.
• Differential diagnosis: A list of potential diagnoses considered by the provider, typically ranked by likelihood.
• Assessment of progress: Evaluation of any changes or developments in the patient's condition since the client's chief complaint, if applicable.

Plan:

• Treatment plan: Specific steps and interventions planned to address the patient's condition, including medications prescribed, procedures recommended, therapies initiated, and lifestyle modifications.
• Education: Information provided to the patient about their condition, treatment options, and self-care measures.
• Follow-up: Plans for subsequent visits or monitoring, including scheduling follow-up appointments or referrals to specialists.
• Prognosis: Discussion of the expected course of the patient's condition and potential outcomes. SOAP note template

SOAP note example

Here is a basic example of how a SOAP note format usually looks:

SOAP Note Example: Abdominal Pain

Subjective (S):

• Chief Complaint (CC): "Stomach pain for the past 3 days."
• History of Present Illness (HPI): The patient, patient's age, reports cramping pain in his lower abdomen that started 3 days ago. The pain is constant but worsens after eating. He also reports bloating, nausea, and occasional loose stools. He denies fever, vomiting, or blood in the stool.
• Past Medical History (PMH): No significant past medical history or surgical history.
• Social History (SH): Denies smoking or illicit drug use. Drinks alcohol occasionally. Eats a regular diet.
• Family History (FH): No history of inflammatory bowel disease in the family.

Objective (O):

• Vital Signs: Temperature 98.6°F, Heart Rate 80 beats per minute, Blood Pressure 120/80 mmHg, Respiratory Rate 16 breaths per minute, Oxygen Saturation 98% on room air.
• Physical Exam: Abdomen mildly distended and tender to palpation in the lower quadrants. No guarding or rebound tenderness. Bowel sounds are present.
• Diagnostic Tests: Basic blood tests and urinalysis were performed within normal limits.

Assessment (A):

• Differential Diagnoses: 1. Irritable bowel syndrome (IBS) 2. Acute gastroenteritis 3. Appendicitis (less likely due to absence of fever and migration of pain)
• Diagnosis: Irritable bowel syndrome (IBS) is most likely based on the patient's symptoms and lack of concerning findings on physical exams and initial tests.
• Prognosis: IBS is a chronic condition, but symptoms can be managed with dietary changes, medications, and stress management.

Plan (P):

• Treatment: Recommend a low FODMAP diet (eliminates certain fermentable carbohydrates) and discuss stress management techniques. Consider adding an antispasmodic medication if cramping pain persists.
• Disposition: Discharge home with a follow-up appointment in 2 weeks.
• Education: Provide the patient with information on IBS and dietary modifications.
• Follow-up: Schedule a follow-up appointment in 2 weeks to assess response to treatment and discuss any further management options.

SOAP Note Template Examples

        1. General medical encounter

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        2. Pediatric well-child visit

        3. Psychiatric follow-up

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Tips For Writing SOAP Notes

Writing effective SOAP notes is crucial for maintaining clear and concise documentation in healthcare. Here are some tips to help you write SOAP notes effectively:

General Tips:

• Timing: Don't write SOAP notes during the patient encounter. Ideally, complete them shortly after the visit while details are fresh in your mind.
• Accuracy and completeness: Ensure all information is accurate, relevant, and clearly documented.
• Conciseness: Strive for clarity and completeness, but avoid unnecessary wordiness.
• Professionalism: Maintain a professional tone and avoid jargon or slang.
• Objectivity: Present facts without personal opinions or judgments.

Structure and Content:

• Standardized format: Use a consistent format for all SOAP notes to ensure ease of reading and information retrieval.
• SOAP flow: Ensure a logical flow between sections, connecting subjective complaints to objective findings and leading to a clear assessment and plan.
• Abbreviations: Use standard medical abbreviations only if they are widely understood.
• Proofreading: Proofread your notes carefully before finalizing them.

Additional Recommendations:

• Patient representation: Consider how the patient is portrayed; focus on objective findings and avoid judgmental language.
• Wording: Avoid tentative language ("may" or "seems") and absolutes ("always" or "never").
• Clarity: Use clear and concise language understandable to other healthcare professionals to avoid
• Cultural sensitivity: Be mindful of cultural factors that might influence patient communication.

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Conclusion

Effective communication and clear documentation are essential for productive meetings. SOAP notes provide a structured framework for capturing details and ensuring everyone is on the same page. However, manually creating notes can be distracting and time-consuming. This is where Bluedot comes in.

Bluedot goes beyond just transcription, offering a solution to streamline not only your meetings but also your patients medical records. With its AI-powered features, Bluedot automatically transcribes meetings, allowing you to focus on the discussion rather than note-taking. Bluedot also excels at capturing screen sharing sessions. This ensures all the information shared, both verbally and visually, is preserved for future reference.

Bluedot even auto-generates emails, meeting templates and securely saves your Google Meet recordings for later access.

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FAQs

Who uses SOAP notes?

SOAP notes are used by healthcare providers across various disciplines, including physicians, nurse practitioners, physician assistants, nurses, therapists, and other allied health professionals.

How do SOAP notes differ from other medical documentation formats?

SOAP notes are structured into four distinct sections (Subjective, Objective, Assessment, Plan), whereas other formats may vary in structure and emphasis. For example, progress notes may focus more on narrative descriptions of patient status without distinct sections.

Can only health care providers use soap notes?

SOAP notes are typically used by a healthcare provider for documenting patient encounters in medical settings especially for the subjective and objective sections. However, variations of structured documentation inspired by SOAP notes may be used in educational, research, and social service contexts to organize observations and assessments systematically.
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