SOAP NOTES
Summary
TLDRThis video script offers a fundamental introduction to SOAP notes, a critical documentation tool in healthcare settings. It outlines the structure and purpose of SOAP notes, emphasizing their role in patient record-keeping and interprofessional communication. The acronym SOAP stands for Subjective, Objective, Assessment, and Plan, with each section containing specific subparts tailored to the patient's needs. The script walks through an example SOAP note for a 62-year-old male with a sore throat, detailing each section's content, from the patient's reported symptoms to the healthcare provider's assessment and proposed treatment plan.
Takeaways
- 📝 SOAP notes are essential for documentation and communication in healthcare settings, serving as a permanent medical record of patient interactions.
- 🔤 The acronym SOAP stands for Subjective, Objective, Assessment, and Plan, which are the four main parts of a SOAP note.
- 🗣️ The Subjective section includes patient-reported information such as symptoms, their severity, and timing, gathered through conversation and medical record review.
- 🔍 The Objective section records the healthcare provider's observations and findings from the physical examination, excluding patient-reported information.
- 🏥 The Assessment part synthesizes information from the Subjective and Objective sections to form a professional judgment about the patient's condition.
- 📋 The Plan outlines the actions to be taken, which may include treatment plans, prescriptions, referrals, patient education, and follow-up instructions.
- 👨⚕️ SOAP notes are used across various healthcare disciplines and can vary in length and detail depending on the situation.
- 📚 A comprehensive SOAP note, often referred to as a history and physical, reviews and documents all possible sections, while more focused notes may only include relevant sections.
- 👴 The example provided illustrates a SOAP note for a 62-year-old male with a sore throat, including his chief complaint, history of present illness, examination findings, and the subsequent plan of action.
- 💊 The plan may involve specific treatments like prescriptions, lifestyle advice, and follow-up appointments, tailored to the patient's diagnosed condition.
Q & A
What is the primary purpose of SOAP notes in healthcare settings?
-SOAP notes are used for documentation and communication, providing a record of patient interactions that becomes part of their permanent medical records, and facilitating communication with future caregivers.
What does SOAP stand for in healthcare documentation?
-SOAP stands for Subjective, Objective, Assessment, and Plan, which are the four main parts of a SOAP note.
What kind of information should be included in the Subjective section of a SOAP note?
-The Subjective section should contain information gathered from talking to the patient, family members, and medical record review, including the patient's symptoms, their timing, severity, and any associated or absent symptoms.
How should the Objective section of a SOAP note differ from the Subjective section?
-The Objective section should only contain the healthcare provider's physical findings and observations, such as vital signs, general appearance, and results from systems examinations, without any patient-reported information.
What is the purpose of the Assessment section in a SOAP note?
-The Assessment section combines information from the Subjective and Objective sections to determine what the healthcare provider thinks is going on with the patient, which may include a differential diagnosis and billable medical diagnoses.
What actions can be included in the Plan section of a SOAP note?
-The Plan section outlines the actions to be taken, which may include ordering prescriptions, requesting consultations, providing patient education, setting follow-up appointments, and managing the patient's condition with treatments and diagnostics.
Why is it important to be concise when documenting the Chief Complaint in the SOAP note?
-Being concise helps ensure that only the most important information is summarized, making it easier for future healthcare providers to quickly understand the patient's primary concern.
Can you provide an example of how to document a patient's history of present illness in the SOAP note?
-An example includes noting the patient's age, existing medical conditions, the chief complaint, the severity and duration of symptoms, associated symptoms, and any relevant medical history or allergies.
What should be included in the General Survey when documenting a patient's examination in the Objective section?
-The General Survey should comment on the patient's overall appearance, level of consciousness, and any signs of distress.
How does the healthcare provider use the information from the Objective section to form an Assessment in the SOAP note?
-The healthcare provider uses the objective findings to support or refute the subjective information, leading to a clinical picture that helps in formulating a diagnosis and differential diagnoses.
Why is it important to include follow-up instructions in the Plan section of a SOAP note?
-Follow-up instructions are important to ensure the patient's condition is monitored and managed effectively, and to provide guidance on when to seek further medical attention if the condition changes or does not improve.
Outlines
📄 Introduction to SOAP Notes
This paragraph introduces SOAP notes, a key tool for documentation and communication in healthcare. It explains how SOAP notes are used to record patient interactions and become part of their medical history. SOAP notes facilitate communication between healthcare professionals, helping them track patient progress. The paragraph also outlines the widespread use of SOAP notes across various health disciplines and introduces the structure: Subjective, Objective, Assessment, and Plan.
🧾 SOAP Note Structure Overview
This paragraph breaks down the four main parts of the SOAP note: Subjective (what the patient reports), Objective (clinical findings), Assessment (diagnosis or evaluation), and Plan (treatment and next steps). The basic structure remains consistent across different medical situations, though the details may vary. It emphasizes that SOAP is an acronym to help healthcare providers remember the format and content required for each section.
🗣️ The Subjective Section: Patient Input
The subjective section is explained as the part of the SOAP note that involves gathering information from the patient, their family, or medical records. This part may include symptoms, personal or family history, and any concerns relevant to the patient’s condition. The detail level varies depending on the type of visit (e.g., routine checkups versus post-surgical notes). Key points include focusing on relevant details and keeping it concise.
🔬 The Objective Section: Clinical Observations
The objective section focuses on the healthcare provider’s observations, such as vital signs, physical exam findings, and test results. It excludes subjective input from the patient. The section must be fact-based, including measurable data like heart rate, blood pressure, or findings from a system examination. The amount of detail varies depending on the reason for the visit.
🧠 The Assessment Section: Diagnosis and Analysis
The assessment section combines information from the subjective and objective sections to form a diagnosis or evaluation. It can range from a general statement to a detailed differential diagnosis, depending on the healthcare provider’s perspective. This section may also include billable diagnoses for which the patient is being seen.
📝 The Plan Section: Treatment and Next Steps
This paragraph explains the plan section, where the healthcare provider outlines the next steps for treatment, including medication, tests, and follow-up. The plan could include ordering lab tests, prescribing treatments, or recommending lifestyle changes. It’s also where patient education, guidance, and future appointments are noted.
🧑⚕️ SOAP Note Example: Mr. Fred K. Aloha
An example SOAP note is provided for Mr. Fred K. Aloha, a 62-year-old male with a sore throat. The subjective part includes his history of hypertension, symptoms, and recent flu shot. The objective part details his vital signs and physical examination, noting throat inflammation and cervical lymph node tenderness. The assessment suggests streptococcal pharyngitis and uncontrolled hypertension. The plan includes prescribing penicillin, increasing his hypertension medication, and providing supportive care instructions.
🏥 Final SOAP Review and Further Learning
This paragraph concludes by reviewing the SOAP note structure: Subjective (patient-reported information), Objective (observed clinical facts), Assessment (diagnosis), and Plan (treatment and follow-up). It encourages further learning on the subject, especially for nurse practitioner students, by offering more detailed lectures available later.
Mindmap
Keywords
💡SOAP Note
💡Subjective
💡Objective
💡Assessment
💡Plan
💡Chief Complaint
💡History of Present Illness (HPI)
💡Physical Examination
💡Differential Diagnosis
💡Medical Record Review
💡Patient Education
Highlights
Introduction to SOAP notes, a fundamental documentation and communication tool in healthcare settings.
SOAP notes serve as a permanent medical record and aid in communication among healthcare team members.
The acronym SOAP stands for Subjective, Objective, Assessment, and Plan, which are the four main parts of the note.
Subjective section includes patient-reported information, family reports, and medical record reviews.
Objective section records the healthcare provider's physical findings and observations.
Assessment is based on the information gathered and may include differential diagnosis and medical diagnoses.
The Plan outlines the course of action, which could involve prescriptions, treatments, and follow-up instructions.
SOAP notes vary in length and detail depending on the healthcare situation and discipline.
A comprehensive SOAP note includes a detailed history and physical examination.
Focused SOAP notes, such as post-surgical progress notes, include only relevant sections.
The patient's chief complaint is summarized concisely in the Subjective section.
History of present illness includes the patient's story and relevant medical history.
Vital signs and physical examination findings are documented in the Objective section.
Assessment combines subjective and objective information to form a diagnosis.
The Plan section may include referrals, prescriptions, and patient education.
Example SOAP note for Mr. Fred K Aloha, a 62-year-old male with a sore throat.
Chief complaint and history of present illness are documented in the Subjective section of the example.
Objective examination findings include vital signs and throat examination results.
Assessment in the example suggests streptococcus pharyngitis and uncontrolled hypertension.
The Plan for Mr. K Aloha includes antibiotic prescription and follow-up instructions.
Transcripts
hello welcome back today we're going to
talk about soap notes this is just the
basic introduction to soap notes for
those interested in or about to work in
healthcare
settings the soap note is really used
for documentation and communication we
document and interaction with the
patient so that we have a record of what
happened that record then becomes part
of their permanent medical records we
also document to communicate with our
future selves and other Healthcare team
members that might need to know what's
going on with the patient soap not are
used across many disciplines within the
health services the information and
length changes depending on the
situation but the basic structure
Remains the Same today we're going to
talk about the basic soap note structure
and what a medical soap note would look
like there are four main parts to the
soap note and each part has a couple Key
subp Parts luckily the name soap is an
acronym and reminds you what those parts
are s stands for subjective o for
objective a is assessment or what you
think is going on with the patient and P
is the plan of
action the subjective section of your
soap note should contain information
gathered by talking to the patient the
family members and the medical record
review depending upon the nature of the
encounter it may include any or all of
the following sections I've listed here
in a comprehensive or really expanded
soap note most often called a history
and physical you will review and
document all of these sections for more
focused notes like postsurgical progress
notes or sick visits you'll include only
those sections that are important to the
encounter remember the O stands for
objective this is where you record your
physical
findings this section should not contain
anything the patient has told you note
only your objective observations also
you may use information such as age and
laboratory diagnostic test results but
remember it's just the facts this
section should contain notes about the
patient's General appearance their vital
signs and findings from the systems
examination like Eyes Ears Nose and
Throat cardiac and respiratory the
amount that you review and document
really depends on the reason you're
seeing the patient moving on the
assessment portion of the soap note is
really based on the information you
gathered in the subjective and objective
sections so it combines all the
information you have so far and allows
you to be able to decide what you think
is going on with the
patient depending on who's writing the
note the information in this section
could be left as a general statement of
what might be going on or it could
include more detailed information like
the differential diagnosis and a list of
billable medical diagnosis that you're
seeing the patient for
today finally the plan is where the
writer gets to decide what to do this
can include ordering or requesting
consultations if it's a medical
clinician writing the note then it may
include prescriptions treatments and
Diagnostics like chest x-rays it could
also include patient education and
anticipatory guidance and then
directions on on when the patient should
follow up are also really
important okay so now you know the
basics of the soap note so let's go
through an example and put this all
together today we're going to see Mr
Fred K Aloha he's a 62-year-old male who
brings himself to the clinic complaining
of sore throat so let's walk through and
actually write the soap note the first
part is a summary of what the patient
tells you when you document you want to
be concise and only summarize the
important information like the timing
and severity of the symptoms and any
other symptoms that are or aren't
present so I'm going to document that Mr
K Aloha is in today with a sore throat
that's going to be the chief complaint
the history of present illness or the
story of the chief complaint is going to
start with he is a 62y old male with a
history of hypertension and he presents
today with six out of 10 constant pain
worse at night started two days prior to
the visit he has Associated symptoms of
fever T Max of 102 he denies headache
ritis gestion sinus or facial pain
nausea emesis cough or shortness of
breath I know from reviewing his chart
and confirming with him that he has
already had his flu shot for the year
and he is still on linal 10 milligrams
for hypertension he has allergies to
sulfa drugs he doesn't smoke only drinks
socially and denies illicit drug use you
notice that I didn't put anything in
about a social or family history because
that's not really pertinent to this case
let's go on to document the examination
the vital signs include a heart rate of
77 7 respiratory rate of 16 blood
pressure of 158 over 92 and temperature
of 100.3 f for the General survey I
commented that Mr koha was an elderly
male alert and in no apparent distress
his eyes ears and nose examination were
all normal his throat however wasn't the
back of his throat called the posterior
oral fering was red and inflamed his
tonsils were hypertrophied and had a
moderate amount of white exate which is
the medical way of saying he had a bunch
of white junk on big tonsils when I
examined the lift nodes in his neck I
noticed tender anterior cervical nodes
on both sides his heart and long
examination were
normal based on all that information I
can make my assessment or my diagnosis
starting with the global assessment I
summarized that the patient is a
62-year-old male with a history of
hypertension who's in today with sore
throat clinical picture suggest
streptococus fitis due to four out of
five points on the modified Center
criteria different IAL diagnosis
includes viral fitis or retral abscess
I'm going to diagnose him with
streptococus fitis and also uncontrolled
hypertension next you get to develop the
plan for his throat infection I'm going
to prescribe penicilin VK 500 milligrams
three times a day for 5 days I'm going
to have him continue supportive care
with salt water gargling Tylenol and
ibuprofen for pain there aren't any labs
or consultations needed I'm going to
have him follow up in 3 days if no
improvement
sooner if the symptoms worsen for his
hypertension I'm going to increase his
lysopl from 10 Mig up to 20 Mig because
he's not yet to
goal so that's the basic structure of
the soap note subjective or what the
patient tells you objective what you see
assessment what you think is going on
based on the subjective and objective
information and the plan what you're
going to do about it all I go into this
in more detail for the nurse
practitioner students if if you're
interested in learning more you can
check out that lecture
later
Voir Plus de Vidéos Connexes
The Five Step Nursing Process Explained | Intro to ADPIE | Lecturio Nursing
Presentations and Notes - An Introduction
Saponification: Making Soap
Properly Wash Your Car At Home | How I wash My Toyota RAV4
Experiments with the Bubble Model of Metal Structure 1952 - Sir Lawrence Bragg, W.M Lomer, J.F. Nye
Difference Between REST API vs Web API vs SOAP API Explained
5.0 / 5 (0 votes)