SOAP Notes: Understanding What They Are and How They Work
If you spend much time in a healthcare setting, you might hear many people mention SOAP notes. These documents are one of the most important types of medical records. Since their introduction almost 50 years ago, they have become a widespread recording method used by a variety of healthcare providers. Understanding how SOAP notes work can make it easier to provide clients with appropriate care.
What Is a SOAP Note?
A SOAP note is a type of medical documentation that is used for routine entries on people’s health charts. SOAP stands for Subjective, Objective, Assessment, and Plan, which are the four steps involved in writing a SOAP note. Doctors, nurses, and other medical providers use the SOAP format to craft helpful records on a person’s health and status.
SOAP notes are primarily written from one healthcare provider to another. They’re meant to create a straightforward list of information that will travel with the client as they go through the stages of care. SOAP notes are initially written on the person’s chart but are eventually transferred to their medical records. This allows the SOAP note to be retrieved for insurance providers, legal experts, or anyone else who needs to examine the client’s medical history.
What Does a SOAP Note Look Like?
Though the SOAP note format is always the same, different healthcare providers may use different styles for their SOAP notes. Some use short statements like “stomach pain” and “elevated blood pressure.” Others prefer to structure their SOAP note as several short paragraphs with complete sentences. It’s also fairly common for healthcare facilities to use various abbreviations in their SOAP notes. When you look at a SOAP note, you might find several shorthand phrases such as “Dx” instead of “diagnostic test” or “CC” instead of “chief complaint.”
How SOAP Notes Have Changed Over the Years
Where did the idea of SOAP notes come from? This concept originated with Dr. Lawrence Weed in the 1960s. Dr. Weed, a professor of medicine and pharmacology at Yale University, recognized that there was a need for a more organized way of handling records for people with complex medical problems. He originated the idea of problem-oriented medical records that could clearly identify clients’ complaints and note the steps taken to address the complaints.
He then further developed this idea to create the SOAP note format. Originally, SOAP notes were handwritten documents that were mostly passed between doctors. However, as they became more widely adopted, other health practitioners, like nurses, also began to contribute to client records. Many SOAP notes are now electronic. As more and more clinics switch to electronic charts, SOAP notes have transitioned to digital forms that healthcare providers fill out on a computer or other device.
The Four Components of a SOAP Note
To fully understand how SOAP notes work, it’s useful to take a close look at each of the four components of a SOAP note.
This heading refers to the client’s subjective view of their problem. To create the subjective section, the healthcare provider will speak with the client, or if the person is unable to speak, the provider will talk to someone close to them who can report the person’s symptoms, behavior, and health problems.
The subjective section always starts with the person’s chief complaint. This can be things like a stuffy nose, gastrointestinal upset, or trouble sleeping. If a client has multiple complaints, the healthcare provider will note them in order of seriousness. Next, the SOAP note will include a history of present illness, which describes the way the person says their current problem has progressed.
The healthcare provider will then write a brief record of any pertinent medical history and any medications the person takes. Finally, they will conclude the subjective portion of the SOAP with a review of all other systems. This list of things like the condition of a person’s gastrointestinal system and his or her general well-being can uncover more symptoms not reported in the chief complaint.
The objective subheading lists all data collected from the client during the encounter with the healthcare provider plus diagnostic tests performed. This includes taking the person’s vital signs and performing a physical exam. In certain cases, the objective section will also contain the results of any laboratory tests or imaging tests the client took.
When creating the objective subheading, it’s important not to mix up the client’s description of their symptoms with the signs the healthcare provider actually witnesses. For example, if a person says, “My stomach hurts,” that’s a basic symptom that goes under the subjective heading. However, if the provider palpates the abdomen and sees the client wince, that’s an objective sign that should be listed in this section.
During the assessment stage, the healthcare provider uses their expertise to consider which ailments could be causing the issues listed in the subjective and objective sections. The assessment section starts with a problem list. Also known as the diagnosis, this includes all medical problems the healthcare provider believes the client to have. If the person has an ongoing condition, the assessment section can indicate whether the condition seems to be improving, worsening, or staying the same.
The assessment section also includes a differential diagnosis. This is a list of other health problems that could account for the client’s symptoms. It should list all possible diagnoses from most likely to least likely. The differential diagnosis should also include details on why these other diagnoses have been ruled out if any are available.
The final section of the SOAP notes is the plan. The plan describes all additional steps that need to be taken to care for the client. For each problem that the SOAP note has identified, it’s necessary to address the plan for the person’s treatment. Depending on the client’s needs, this plan can be a brief statement such as “no further care needed,” or it can be a complex list of options.
The typical plan section will include things such as which type of tests are needed in the future and what steps should be taken depending on the test results. It should also mention any prescribed medication or therapy and any referrals to other providers such as specialists. The plan must also mention whether the healthcare provider has informed the client about their next steps.
Why SOAP Notes Are Important
As you can see, a lot of detail goes into SOAP notes. All of it is very useful. It provides a fairly broad picture of a client’s health and encourages doctors to go through each step of properly examining the person and assessing their well-being. By requiring healthcare providers to go through defined steps, SOAP notes ensure that important details aren’t forgotten.
The other big advantage of SOAP notes is that they standardize medical notation. Almost every healthcare facility uses SOAP, so it creates a notation style that is very easy for someone to read. A doctor from a different clinic can read SOAP notes and instantly get all pertinent details about the person. Since things are always structured the same way, it’s very easy for multiple providers to coordinate client care. A person’s healthcare can remain consistent even if they’re being treated by multiple professionals.
Limitations of SOAP Notes
While SOAP notes are very useful, they can’t solve every challenge associated with keeping medical records. Some professionals worry that SOAP encourages too many abbreviations and too many shorthand terms. The lack of detailed descriptions can potentially lead to some misunderstandings, and SOAP notes aren’t always accessible when a nonmedical reader tries to understand them. Solving this issue often requires specialized training for all staff members who write SOAP notes.
SOAP notes can also provide some challenges in healthcare fields that don’t focus on diagnosis and immediate treatment. The format does not allow providers to make note of long-term goals or desired functional outcomes. This can make SOAP notes a little difficult in fields like physiotherapy. To address the issue, some medical professionals recommend adding a subsection to compare the client’s current status to their previous status and assess how well the plan has worked so far.
Tips for Creating the Best SOAP Notes Possible
Creating an excellent SOAP note is a learned skill. The best SOAPs provide a full picture of the client’s health while being short and concise. Here are some tips that healthcare providers can use to improve the SOAP notes in their facilities.
- Avoid using non-standardized abbreviations. Whenever possible, write out the full name of a concept instead of using an abbreviation that can be easy to misunderstand.
- Be as specific and accurate as possible. Only write facts you know; avoid making any vague conclusions.
- To fill out the subjective section, ask clients open-ended questions instead of ones that can be answered with just a “yes” or “no.”
- When writing the objective section, avoid any statements that cannot be supported with clear data.
- In the plan section, focus on the next steps. This can help you avoid rewriting things already stated in the client’s current treatment plan.
- Prioritize simplicity and ease of understanding when you write your SOAP notes. Remember that you are writing them for others, not just for yourself.
- Fill in the information on your SOAP notes template as you get it instead of waiting until you have it all. This will minimize the chance of forgetting any important details.
- Don’t hesitate to work with digital tools. Modern SOAP note templates can make it a lot easier for healthcare providers to craft excellent notes.
For the most effective SOAP notes possible, turn to AutoNotes. Our templates make it easy to create clear, well-organized SOAPs. We also offer a variety of other medical record services, including HIPAA-compliant storage and automatic note generation. Contact us now to learn more.