Understanding SOAP Notes: A Comprehensive Guide for Medical Professionals
Healthcare providers face a challenging task when seeing patients. They need to gather enough information to determine the problem without getting overwhelmed by unnecessary details shared by the patient. Luckily, the SOAP Notes method has streamlined office visits, making them less confusing and awkward. If you're unfamiliar with SOAP Notes, keep reading to learn more.
What Do SOAP Notes Consist Of?
SOAP is an acronym for Subjective, Objective, Assessment, and Plan. Let's dive into each section and understand their significance in the SOAP Notes method.
The subjective section of a medical visit provides an opportunity for patients to share their experiences and feelings regarding their current health state. A thorough "Subjective" section typically contains a wide range of details obtained through a patient interview. Below are the key elements found in the "subjective" portion of SOAP Notes:
Chief Complaint - The Chief Complaint is the reason why the patient has sought medical care. It may be an existing diagnosis, a previous condition, or a new symptom. The chief complaint gives a quick overview of the reason for the visit. It's important for the provider to listen carefully to understand the full extent of the patient's issues and isolate the most concerning complaint, which may involve multiple presenting problems.
History of Present Illness (HPI) - The History of Present Illness (HPI) allows the practitioner to delve deeper into the patient's complaints. It typically begins with a short, concise statement such as, "68-year-old patient presents with severe right knee pain." The OLDCARTS mnemonic is often used to collect more detail and organize the information.
Onset: When did the chief complaint become apparent?
Location: Where is the chief complaint located in the patient's body?
Duration: How long have the chief complaint's symptoms been present?
Characterization: How does the patient describe the nature of the pain or discomfort?
Alleviating/Aggravating factors: Is there anything that makes the symptom better or worse?
Radiation: Does the symptom stay in one place or does it travel to other areas of the body?
Temporal factor: Is there a certain time of day when the symptom worsens?
Severity: A scale from 1 to 10 is used to rate the intensity of the symptom, with 1 being the least intense and 10 being the worst.
A systematically obtained history helps establish a broader picture of the patient's overall health and provides insight into why they may be experiencing their current chief complaint. A useful history includes:
Medical history: Relevant past and present conditions or illnesses.
Family history: Pertinent information on the medical conditions of immediate family members, including parents and siblings. In some cases, it may be useful to include information about significant and potentially hereditary conditions of grandparents.
Surgical history: All surgeries, including the date and the name of the surgeon who performed the procedure.
Social History: This section addresses lifestyle and environmental factors. The HEADSS acronym is often used to cover this portion of the patient's history. HEADSS stands for Home/Environment; Eating, Education, and Employment; Activities (including hobbies); Drugs; Sexuality; and Suicide/Depression.
Review of Systems (ROS)
The ROS is used to reveal symptoms or complaints that may otherwise remain unmentioned. Often, the ROS will bring to light other systemic issues that may contribute to the chief complaint.
Some of the questions covered by the Review of Systems should include:
General: Is the patient eating and drinking normally? Have they noticed any unexplained weight loss or weight gain? How is their energy level?
Gastrointestinal: Has the patient noticed changes in their digestive function? Diarrhea or constipation? Abdominal pain?
Musculoskeletal: Are there any new aches, pains, or limb weakness? If so, where are they?
A list of the current medications the patient is taking is helpful to understand the treatments the patient is receiving. It is also extremely important to have this information so that drug interactions can be avoided when prescribing new medications. The name of the patient's current medications, along with dosage and frequency should be noted.
Recording any allergies a patient has may aid in diagnosing the chief complaint. This information is also necessary to avoid prescribing treatments or medications that may cause an allergic or anaphylactic reaction.
The objective portion of the SOAP Note includes unbiased, factual information from the patient's visit. It should include:
Findings from the physical exam
Imaging and other diagnostic results and data
Review and recognition of any consult documentation from other practitioners
The assessment section consists of two important parts: the problem list and the differential diagnoses.
The problem list includes each issue listed in order of significance, typically considered a diagnosis.
The differential diagnoses include other possible diagnoses, also ordered from most to least likely.
The plan section brings everything together. It addresses the need for consultations, additional testing, and details the treatment plan for the patient's conditions and illnesses. The plan section should include:
Which additional testing will be needed and why these tests are thought to provide answers
Specialist consultations or referrals to different practitioners
Treatment needed, such as medications or procedures
Patient instructions and counseling
The SOAP Note is a thorough and complex record of a patient's visit. Historically, it has been a paper-based document, sometimes requiring extensive searching to find specific information. However, the Electronic Health Record (EHR) has revolutionized how practitioners record and access patient data.
The EHR allows a patient's entire medical record, including doctor's notes, lab work, imaging diagnostics, and more, to be centralized in one place. This enables practitioners to quickly reference a patient's past health history and add new information as it becomes available.
How TempDev Helps with SOAP Notes
At TempDev, we are dedicated to helping practices and physicians succeed. NextGen EHR is fully customizable when working with a consulting firm like TempDev, making it an ideal tool for busy healthcare facilities that want high-quality, consistent SOAP Notes. To learn more about how our experienced team of developers and consultants can build your EHR, please don't hesitate to contact us here or by calling us at 888.TEMP.DEV!
Taking SOAP Notes in this order enables practitioners to consistently gain insight into a patient's complaints, covering the important points under each heading.
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