SOAP Notes

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Learn what SOAP notes are, where they are used, and how to write them.

0:01 This short tutorial introduces you to the concept of writing SOAP notes.
0:07 Healthcare professionals methodically record notes of their interactions with their patients in order to provide better care for those patients.
0:15 Such notes are especially important when it’s possible that multiple healthcare providers will work with a patient because each provider can benefit from the key points of previously recorded interactions.
0:26 Patient notes are often called SOAP notes because they typically feature four distinct sections: Subjective, Objective, Assessment, and Plan.
0:38 While SOAP notes provide an effective means of documenting patient interactions for the sake of keeping track of your ongoing work with each patient, they also have external audiences as well.
0:50 Often patients may work with a range of healthcare professionals as they work to resolve a medical issue, so it’s important that each healthcare provider develop careful SOAP notes for each interaction so that subsequent healthcare professionals have a record of previous interactions.
1:06 Other potential audiences for these documents include insurance companies or attorneys for litigation purposes.
1:15 The content of SOAP Notes can vary from one clinical situation to another, but in all cases they should include the patient’s name, your name, and the attending physician’s name.
1:25 Additionally, SOAP notes generally include the following basic categories of information:
1:32 The subjective section includes your impressions of the patient based upon what you observe of them and what he or she tells you.
1:39 This may include, for example, your impression of the patient’s ability to move about easily or communicate effectively along with the patient’s explanation of his or her symptoms.
1:49 The objective section generally includes quantifiable information pertaining to the patient’s health.
1:55 This might include, for example, lab test results, body weight, or even descriptive accounts of what happened during the interaction like, for example, “the patient stumbled while climbing on to the examination table.”
2:10 The assessment section includes your analysis of the interaction, which may include comparative information from previous interactions with the same patient if such interactions have occurred.
2:22 Essentially, in this section, you should draw conclusions about the patient’s health or health progress based upon what you have learned from the patient, what you have observed of the patient, and what you have learned from any obtained measurable patient information.
2:38 In the final section of the document, you draw upon the information you have recorded in the previous three sections to develop an evidence-based plan for the patient.
2:48 This may include tasks for the clinician to undertake prior to a follow up session, tasks for the patient to undertake prior to a follow up session, or referrals to other medical professionals, among other possibilities.
3:03 Given the wide range of potential audiences for SOAP notes, and their importance in patient healthcare, insurance coverage, and legal proceedings, it’s very important to use your words carefully and deliberately when crafting these notes.
3:17 Give yourself enough time to thoughtfully prepare them during or after each patient interaction.
3:23 While abbreviations and a general note-taking style are recommended to save time, take care to ensure that your words accurately capture and express your observations and that your assessment and plan are based upon sound evidence that you have gathered for each specific patient.
3:40 While SOAP notes always provide these four basic categories of information, their specific formatting can vary significantly from one clinical setting to another.
3:50 Each clinical setting, though, should have a specific SOAP notes format that you should learn and follow as you go about your work in it.
3:59 On this page, you see a brief example of SOAP notes.
4:03 As noted previously, formats may differ based on your work context, so be sure to find out what specific format you should follow when documenting your own notes.
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