SOAP notes are commonly used method of synchronizing entire history of a patient for multiple doctors or surgeons. It is a very common thing that a patient is treated by more than one doctor either for the same illness or for various illnesses and in order to make sure that each doctor understand what the actual problem is, how the other doctors diagnosed it and how they treated it, each health care provider is asked to prepare SOAP notes for each of their patients. These notes are then shared with other doctors treating the same patient. SOAP is an abbreviation for Subjective, Objective, and Assessment & Plan. Objective refers to the problem that the patient has according to him or in his or her own words. Objective part includes what the doctor thinks is the best way to treat the condition and what his observations are. Third part being assessment refers to doctor’s evaluation for each part of the treatments. Plan is the fourth portion and it indicates towards the actual plans to treat the patient.
Importance of SOAP Notes:
As a common person who is not a doctor, you can understand that when you go to a doctor, you tell them exactly what you feel or what problem you have and it’s not a problem but what if you have to do it over and over? How will you feel if you are asked to describe your medical condition dozens of times in front of different doctors? Obviously you will not feel comfortable or might not have patience to do it. For the sake of patient’s purpose that he doesn’t need to describe his condition each time a new doctor treats him, SOAP notes are prepared. These notes tell and show complete history of patient and with these notes, the doctor doesn’t need to ask the patient anything but he can find all the details on the notes.
Another important aspect of SOAP notes is that when a patient is treated by multiple doctors either for the same condition or different illnesses, it’s possible that their treatments somehow overlap and create another problem for the patient that was not there in the first place. It’s not uncommon that two doctors treated a patient with different medication and side effects of those medicines together made the condition worse. For eliminating this kind of serious and life threatening problem, doctors share their treatment plans and recommendations on the SOAP notes. When the patient visits another doctor, he can easily check for previously used treatments and medicine that the patient has taken in the past.
The file that contains SOAP notes from various doctors has an added benefit of describing the condition of a patient from the beginning. The file starts with the condition that is described by the patient in his own words and then the same condition or diagnosis is done by the doctor and it’s written in the notes. From the moment a treatment is applied on the patient, it all starts going into the file and months or even years later, any doctor can check the file and see how the condition started, how it was diagnosed, how each doctor treated it and what the outcomes were for each type of treatment.
Free SOAP Note Templates
Here are some Soap Notes Templates:
General Guidelines to prepare SOAP Notes:
- Subjective part:
The SOAP notes start with writing down what the chief condition is according to the patient. This is a part that gives general idea of what the patient is going to through or how he is handling the condition. If compulsory data is not available, you can talk to family members to get better idea of the condition. Whatever the patient says, you need to write it down i.e. chest pain, regular headache, pain in the stomach etc. This part should also include additional information that you can get by questioning the patient. This will include beginning of the condition, location of the condition, if anything makes the condition worse or better, does the condition i.e. pain happens all the time or only in the morning or some other time and most importantly; how does the patient feel about the condition on a scale of 1 to 10 when 10 is highest level of pain.
- Objective part:
This is the second part of SOAP notes and here you need to do some examination of the patient. Starting with taking the blood pressure, measuring the temperature, pulse, breathing and color of the eyes. If there is any abnormality i.e. blood pressure seems to be very high, check it again to make sure there is no error. Next thing would be to check the area of CC i.e. if the patient complains that he is having pain in his chest, ask them to take off their shirt and examine the chest for any physical abnormalities i.e. bruises or spots that indicate blood clots inside the chest. After the initial examination, there might be some need of tests i.e. X-Ray or CT Scan and once these tests are done, write down their results in the SOAP notes as well.
- Assessment part:
This portion of SOAP notes is created by doctors or surgeons. When you are checking a patient and preparing SOAP notes with their medical history, make sure to check if this is the first time patient has visited any doctor or if he was treated by someone else in the past. In case you are not the first doctor they have seen, make sure to mention your observations about if the condition has gotten better or worse after previous diagnoses and treatment. Then it’s time to evaluate symptoms the patient has and then suggest a specific diagnose or treatment following up with the reasons of why you choose this treatment and how it’s going to benefit the patient according to your expertise.
- Plan portion:
Once a specific treatment is suggested by the doctor, next thing would be is to check if any additional tests are required for better understanding. For instance, if the doctor has suggested surgery, it’s important to diagnose the patient for conditions like high blood pressure which can put the surgical process at higher risk. If an operation or surgery is not recommended, there must be some medication that the patient can take. Suggest specific medicine for the patient and in case you want them to see another doctor, give your recommendation on the SOAP notes.
Checkout more free SOAP Notes Templates to assist you in preparing your own SOAP Note quickly and effectively.