What is a SOAP Note?

By | October 24, 2017

What is the Importance of a SOAP Note?

It is very common that the medical professionals use a SOAP Note to record the required information about the patients. The users can record the data as systematic and universal. They can be shared and read easily. The medical records are very important for the health of a patient and so the method which will be used to create these records must be selected attentive and appropriate. You can see 4 parts in this note; objective, subjective, plan and assessment…The medical professionals can get information about the patients’ health; they can also inference about the negative developments as a result of following the note of SOAP.



How to Write a SOAP?

There are different styles for these notes. Your notes should include the explained parts above; an objective, subjective, plan and assessment titles. The first letters of these words constitute the SOAP word. You should choose the appropriate SOAP note format but they vary according to the department, field, patients, workplaces etc. When you write a note, follow the steps below:

  1. Start your note with the subjective part. Write the history of the patient and state the complaints. You may also add some information about the symptoms, pain etc.
  2. Then, you should write the objective part. The information will be placed in this part can be measured by the medical professionals. State the tests etc. Then you should write a comment of what you think about the patient’s situation…The part should include the observations.
  3. The assessment should be recorded in the Assessment part of SOAP. This section should contain the likely diagnosis. If you are not sure of the diagnosis write the possibilities. Add other information related this part.
  4. The last section of SOAP is the plan! Write what you are going to do in the treatment process.


 What are the points to note?

SOAP should be clear and detailed but not type any unnecessary information. Give the sufficient details about the patients because any other healthcare person who doesn’t know the patient before should understand the situation clearly! This a very important point to provide a good and appropriate care for the patient. The style of this note may differ according to the workplace, department, requirements etc. Depending on the format, SOAP may be written with a full paragraph or also by different titles. There are more styles than two. You can use a lot of abbreviations; these are very common in the health sector.



The SOAP Templates

There are many SOAP templates prepared in different styles etc. You can use one of them; some websites offers SOAP templates free of charge. Below, you can review the websites which offers template options:

  1. template.net
  2. freeprintablemedicalforms.com
  3. templates.openoffice.org

With a good SOAP note, the patients can be provided with a better quality care…