SOAP NOTES

Summary

This 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

00:00

📄 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.

05:02

🧾 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.

Keywords

💡SOAP Note

A SOAP note is a standardized method of documentation used in healthcare settings, particularly for patient care. It stands for Subjective, Objective, Assessment, and Plan. The video emphasizes the importance of SOAP notes for clear communication and record-keeping within the healthcare team. An example from the script is the creation of a SOAP note for Mr. Fred K Aloha, detailing his chief complaint, history, examination, and plan for treatment.

💡Subjective

The subjective section of a SOAP note contains information gathered from the patient, such as their symptoms, concerns, and history, as reported by them or their family. It is subjective because it reflects the patient's own perspective. In the script, subjective information includes Mr. K Aloha's report of a sore throat, fever, and the timing and severity of his symptoms.

💡Objective

Objective information in a SOAP note is based on the healthcare provider's observations and findings, such as physical examination results and diagnostic test outcomes. It is objective because it is measurable and verifiable. The script mentions objective observations like Mr. K Aloha's vital signs, the appearance of his throat, and the absence of certain symptoms.

💡Assessment

The assessment part of a SOAP note synthesizes the subjective and objective data to form a professional judgment about the patient's condition. It often includes a diagnosis or an impression of what might be wrong with the patient. In the video script, the assessment considers Mr. K Aloha's symptoms and signs to suggest a streptococcus pharyngitis and uncontrolled hypertension.

💡Plan

The plan section outlines the intended interventions, treatments, or actions to be taken based on the assessment. It may include prescriptions, referrals, diagnostic tests, patient education, or follow-up appointments. The script provides a plan for Mr. K Aloha that involves prescribing penicillin, recommending supportive care, and scheduling a follow-up appointment.

💡Chief Complaint

The chief complaint is the primary reason the patient seeks medical attention at the time of the visit. It is usually the first piece of information documented in a SOAP note. In the script, Mr. K Aloha's chief complaint is a sore throat.

💡History of Present Illness (HPI)

HPI provides a detailed account of the patient's current illness, including the onset, duration, severity, and any associated symptoms. It is part of the subjective section. The script describes Mr. K Aloha's HPI, noting the constant pain, fever, and other relevant details.

💡Physical Examination

This refers to the process of examining the patient using the senses or medical instruments to assess their health status. The objective section includes findings from the physical examination. The script mentions specific findings from Mr. K Aloha's examination, such as his throat being red and inflamed.

💡Differential Diagnosis

A differential diagnosis is a list of possible conditions that could explain a patient's symptoms. It is part of the assessment in a SOAP note and helps guide further investigation or testing. The script lists streptococcus pharyngitis and viral pharyngitis as differential diagnoses for Mr. K Aloha.

💡Medical Record Review

Reviewing the patient's medical record is part of gathering subjective information. It provides historical context and helps inform the healthcare provider's assessment and plan. The script notes that Mr. K Aloha's chart was reviewed, confirming his medical history and current medications.

💡Patient Education

Patient education is an important aspect of the plan section in a SOAP note. It involves informing the patient about their condition, treatment options, and self-care strategies. The script mentions patient education as part of Mr. K Aloha's plan, although specific details are not provided.

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