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Understanding SOAP Format for Clinical Rounds

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What is a SOAP Note?

A SOAP note is very important document which states the patients’ health situation. It is commonly used in the medical sector by the many health care people. “SOAP” word are consisted of; Subjective, Objective, Assessment and Plan. The initial letters create the SOAP. This document mainly shows the medical history of the patient, current situation, complaints or any other notes about the chart of the patient. It is important to use the SOAP in the same format because it allows to tracking the patient easier and clearly. Especially in the same hospital or in the same place, it can lead to serious confusion. Nurses, doctors, therapists, medical students and other clinicians can use SOAP. This document is very important indicator for the patients.

SOAP Note
SOAP Note

How to Prepare SOAP?

SOAP note has 4parts and when you want to prepare SOAP, you should track the order and writing rules. As we explained there are 4 sections in SOAP and you can write the information in accordance with these sections. Review the following items:

  1. Type a “Subjective” Title

In this part, write the patient’s expression about the illness. Don’t write your own evaluation. The symptoms are important for this section. You cannot measure the information that the patient gave you because the same symptom can be expressed in other ways by the different patients. Write the patient’s words.

  1. Type a “Objective” Title

In this section, the objective situations and symptoms are the key points. You can write all the information about every signs that you can measure, see, hear, feel etc. Also you can write the temperature, pulse etc. Focus on the measurable items of the patient.

SOAP Note
SOAP Note
  1. Type a “Assessment” Title

The key points of this section are condition and diagnosis for the patient. Sometimes you may be clear about the diagnosis but sometimes you may not. There may be different possibilities about the patient’s situation.

  1. Type a “Plan” Title

Focus on the surgery or medication at this section of SOAP. You should write your plan to solve the patient’s health trouble.

When you prepare your SOAP be careful the order of the titles. The order must be as same as the above.

 

SOAP Note
SOAP Note

The points to note in SOAP

There are some important points that you should be careful to create your SOAP:

  • Be very careful about the clarity of the information
  • Write the SOAP in the same format
  • Your writing should be clear
  • Write the most important necessary information about the patient
  • Write the measurable values to remember the information about the patient
  • You don’t need to write for public you can use the medical terms
SOAP Note
SOAP Note

Where can you find the SOAP Templates?

As we explained it is better to use the same SOAP format in the same and related places. When you want to choose the SOAP format, you can review the templates at many websites. Templates are ready and generally in blank formats or may include the directions. Here are some of the websites:

  1. pinterest.com
  2. worldlabel.com
  3. template.net
  4. brambleberry.com
  5. free-css.com

Use a free SOAP note template and edit it easily!

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