5 Tips for Taking Better SOAP Notes
Using a standard for documenting your visits with patients will help you create better patient notes and more comprehensive medical records. By taking contemporaneous notes of your patient’s complaints, your observations, treatments being performed, and plan for future treatments, you will find focusing on finding a solution much easier. The most common note taking template for medical professionals is known as the SOAP note.
SOAP is an acronym which stands for subjective, objective, assessment, and plan. By following the SOAP note taking format you will create a standard for organizing and documenting all of your patient’s information during your visits. Doing so means that you will be able to devote more of your energy towards figuring out what’s wrong and finding ways to help the patient easier. Taking contemporaneous notes of your visit with the patient will save you the time of trying to recreate your notes later. By using SOAP notes you can organize your patient’s symptoms, keep track of your observations, assessments, and the treatment plan.
The subjective section contains information that the patient is telling you. This section includes reported symptoms which cannot be seen and measured as well as the Patient History, Chief Complaint, Mechanism of Injury, Pain Description, and Social History. To make sure that you obtain enough information to complete the subjective section of your SOAP notes contemporaneously, use the mnemonic O.P.Q.R.S.T. which is described as follows:
Onset: How long has the problem been going on for?
Palliation/Provocation: Does touching or anything else make it better or worse?
Quality: What does the pain or having the problem feel like?
Region/Radiation: Where is the pain and does it extend into other regions?
Symptoms/Severity: What other symptoms do you get?
Timing: Does the pain happen at certain times or is it continuous?
The objective portion of your SOAP notes goes over your observations of the patient. Take contemporaneous notes of observations related to the patients Chief Complaint. The longer you wait the less you’ll be able to recall. Data in this section may include the results of any follow up tests, physicals or fitness tests performed, new medications, changes to current medications, and potential side effects of medications. Everything included in the objective section of your SOAP notes includes symptoms that can actually be seen, heard, touched, felt, smelled, or measured. Even if your patient doesn’t complain of any other symptoms make sure to screen for symptoms in each body system. Doing so means you’ll have an easier time making the correct diagnosis. Some of the major body systems you may have to ask about are as follows:
Even if you may not be qualified to diagnose your patient with a condition outside of your specialty, checking other body systems is a prudent practice and can help you rule out any unclear diagnoses in your scope of care. Checking your patients other body systems also means you can coordinate the patient’s treatment with other specialists and provide a higher level of care.
The assessment section is where you take contemporaneous notes to document important changes in the patient’s condition. This section will also include the patient’s diagnosis. In some cases a patient’s diagnosis is clear. For example a patient admitted after a car accident will have diagnoses such as abrasions, contusions, concussions, and other type of conditions you’ll find in people who were just in a car accident. In other cases the diagnosis may not be clear and additional review and assessment may be required. If a final diagnosis hasn’t been made yet you can also include the possible diagnoses as well as any diagnoses that have already been ruled out in this section.
The final section of your SOAP notes is the Plan section. After the necessary information has been gathered for the subjective, objective, and assessment information, you will have to take contemporaneous notes to outline what steps will be taken to treat the patient. This section should include information such as the plan for medication, therapy, and surgeries. Any long term plans of treatment should also be included in this section as well. Listing goals that you would like to accomplish with the treatment will help you accomplish your goals with the patient and make sure you stay on track with providing the highest level of care to the patient.
Common SOAP Note Abbreviations
When taking contemporaneous notes of your interactions with patients you will come across a lot of similar information that you will need to fill out. Taking the time to write out everything you need to can be time consuming and take up a lot of mental energy that you could use towards helping more patients and ruling out possible diagnoses. It’s for this reason why medical abbreviations were created. Using medical abbreviations can help you save time and clear your mind so you can focus on helping more of your patients. Some common abbreviations you may end up using when creating your SOAP notes are as follows:
- CC = Chief Complaint
- WT = Weight
- HT = Height
- IBW = Ideal Body Weight
- BP = Blood Pressure
- Chol = Cholesterol
- Pt = Patient
- RTO = Return to Office
- ROM = Range of Motion
- R/O = Rule Out
- PA = Posterior/Anterior
- P = Pulse
- T or temp = Temperature
- NKDA = No Known Drug Allergies
- NKA = No Known Allergies
- BS = Blood Sugar
- UA = Urinalysis
- VA = Vision Acuity
- OS = Left eye
- OD = Right eye
- OU = Both eyes
Writing Better SOAP Notes
SOAP notes create a standard and organized way of documenting patient information. Medical professionals such as nurses, doctors, counselors, athletic trainers, and so on use SOAP notes to document the patient’s progress and communicate with each other to maintain continuity of care. Taking contemporaneous notes is a crucial part of making the best possible SOAP notes for all patients. The following tips will help you take better SOAP notes So you’ll spend less time thinking about what to write and spend more time writing.
1. Organize Your Thoughts
Though you want to take notes after your encounter with your patient, taking a few minutes to think about what you want to write before starting your SOAP notes will avoid wordiness. You should still take contemporaneous notes of your patient encounter but some patient visits may require a little filtering. For example a patient may be coming in because of back pain. However, they may have spent a large portion of the visit complaining about how bad their allergies have also been lately. If the chief complaint they came in for is back pain, any sort of information about allergies should be toned down unless a new course of treatment has been decided upon for that condition as well.
2. Summarize the Visit
It’s generally not required to quote a patient on their symptoms unless they used very specific words that may help with their treatment. If a patient goes on a tangent and gives extra detail about their symptoms it’s appropriate to omit any extra details that don’t help with their treatment out from your notes. Any information that the patient gives out that doesn’t help with their general health and well being should be left out. Personal and confidential information should never be included in your contemporaneous notes of your visit with the patient.
3. Stay within Your Scope of Practice
When making a diagnosis of your patient it’s very important to stay within your specialty. If you are not a psychiatrist you shouldn’t be attempting to diagnose psychological or eating disorders. Likewise if you are a mental health professional you should not be diagnosing your patient with arthritis even if you are sure that they have it. If you suspect your patient has another condition they need help with, you should refer them to another doctor. Diagnosing patients outside of your scope of practice comes across as judgmental. However, referring patients to a specialist is considered highly professional. Be sure to take plenty of contemporaneous notes of your observations that make you believe that the patient has the condition. Your notes will give the other medical professionals additional help in diagnosing the patient with the right condition.
4. Underline Abnormal Findings
Medical professionals likely see many SOAP notes throughout their day as they go about the treatment of patients. It’s easy for important information to get glazed over. To ensure that your notes will be used to the full extent it helps to underline any abnormal findings you come across as you write your contemporaneous notes of your patient encounter. Anything else important that can determine the course of treatment should also be underlined. For example side effects of medications, new symptoms, and unexplainable symptoms should all be underlined for the next medical professional to take special note of.
5. Avoid Excessive Acronyms and Abbreviations
When creating your SOAP notes it’s important to remember that other medical professionals may need your notes to treat other conditions the patient may have or will have. If you use an acronym or abbreviation be sure to use one that is official and not one that is just made up by yourself or another medical professional. If you know that other medical professionals will likely understand your abbreviations it becomes professional and prudent to use it instead of writing out the whole word and wasting time.
SOAP notes are a simple yet comprehensive technique used by all medical and mental health providers. It was developed in the late 1960s as a means of organizing symptoms, observations, assessments, and the treatment plan to improve communication among all medical professions caring for a patient. By taking contemporaneous notes of your patient encounters you will find it’s much easier to organize complex problems into simpler parts. Doing so means that caring for the patient is easily tracked and conditions are managed or resolved. SOAP notes also helps medical professionals identify obstacles in the patient’s care and provides concrete evidence of progress. By following the 5 above mentioned tips you will find using SOAP notes to be extremely beneficial, display professionalism, build trust and credibility for all medical professionals involved with the care of the patient.