If you are one of those who i working in a hospital, you might be familiar with SOAP note example. Have you ever heard about SOAP before? If not, let’s take a look at it. SOAP is an abbreviation of subjective, objective, assessment, and plan.
For further explanation, SOAP is a document used by medical personnel to record patient information during treatment. Medical personnel who use SOAP records are nurses, therapists, athletes coaches, health consultants, and doctors. Not only as a record of recording patient information, but SOAP notes can also be used as a tool to communicate data to health care providers if patients do not have the opportunity to meet and speak directly.
The definition of SOAP note
It has been explained that SOAP stands for subjective, objective, assessment, and plan. However, what exactly are the intentions of those four words? To find out then see the explanation below.
- Subjective : is a word that refers to everything the patient has to say about, concern, issue, problem and intervention procedure. In this section, you can write down subjective findings based on medical reports.
- Objective : this section refers to what has been observed and examined by health personnel and what treatment steps or procedures will be taken by medical personnel. Usually observed are visibility, waist circumference, soft and hard tissue palpation, active range of motion, passive and resistive or ROM (Range of Motion) – AROM, PROM, RROM, blood circulation, manual muscle test results, and neurological assessment.
- Assessment : this section refers to the diagnosis and possible analysis of various components included in the assessment. You can write a diagnosis that is possible if you have not received a final diagnosis.
- Plans : this section refers to procedures that will be taken or used by health care providers to treat patients or achieve predetermined goals. In this section you can write it down like a therapeutic process, type of medicine or if it is through surgery then what method will be done.
How to make SOAP notes
SOAP note is a written document that must be structured. Therefore, SOAP note example are needed so that there is an appropriate format. To make a SOAP note example is an easy job. The following are tips on making a SOAP note example:
- Start with the contents in the subjective section whose information can be obtained from the patient.
- You need to know what questions should be asked to patients to fill the subjective component. Avoid to ask a yes no question.
- After you have finished filling in the subjective section, you can continue in the second part, namely objective. This section will contain what you have observed from the patient.
- After that you can check the patient. When conducting an examination you can ask questions and examinations if needed.
- Evaluate the results of the examination and the symptoms that have been carried out.
- Document and record the assessment has been carried out and make a list of diagnoses then arrange the possibilities of diagnosis until you get the final diagnosis. Make sure that all notes are not left behind.
- After getting the final diagnosis, write down the planned actions and treatments and make them in detail as a reference for daily procedures.
SOAP note example is a written data record containing patient information. Therefore the steps in writing a SOAP note are important to note in order to get accurate patient care information.