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How to Write a SOAP Note:

Medical documentation of patient complaint(s) and treatment must be consistent, concise, and comprehensive. Many medical offices use the SOAP note format to standardize medical evaluation entries made in clinical records. The four parts of a SOAP note are outlined below.

1. SUBJECTIVE - The initial portion of the SOAP note format consists of subjective observations. These are symptoms verbally given to medical assistants by the patient or by a significant other (family or friend). These subjective observations include the patient's descriptions of pain or discomfort, the presence of nausea or dizziness, and a multitude of other descriptions of dysfunction, discomfort, or illness.

2. OBJECTIVE - The next part of the format is the objective observation. These objective observations include symptoms that medical assistants can actually see, hear, touch, feel, or smell. Included in objective observations are measurements such as temperature, pulse, respiration, skin color, swelling, and the results of tests.

3. ASSESSMENT - Assessment follows the objective observations. Assessment is the diagnosis of the patient's condition. In some cases the diagnosis may be clear, such as a contusion. However, an assessment may not be clear and could include several diagnosis possibilities.

4. PLAN - The last part of the SOAP note is the plan. The plan may include laboratory and/or radiological tests ordered for the patient, medications ordered, treatments performed (e.g., minor surgery procedure), patient referrals (sending patient to a specialist), patient disposition (e.g., home care, bed rest, short-term, long-term disability, days excused from work, admission to hospital), patient directions, and follow-up directions for the patient.

See SOAP Note example!

Don't misunderstand a progress note vs. a SOAP note! As the name implies, a progress note sums up the progress that has been made in the patientís care since the last note. SOAP stands for subjective, objective, assessment, and plan. The SOAP note is a brief report in the patient's chart, done at the day of the appointment when the patient is seen. It is different from the comprehensive progress note the doctor writes in the physical diagnosis.

The instructions below should give you a general idea of what information to include and where. Many of the particulars of your notes will be different for each medical specialty, so be sure to get feedback from your medical office manager and coworkers about your notes as early as possible, and adjust your style accordingly.

The SOAP note should briefly express the following:
(1) Date and purpost of the visit. The patientís symptoms and complaints.
(2) The current physical exam. What is the patient's height, weight, temperature, pulse, blood pressure, visual acuity, etc.?
(2) New lab data and results of studies, reports, assessments.
(3) The current formulation and plan for the patient.

The SOAP Note:
Remember, the SOAP note is not supposed to be as detailed as a progress report.  Complete sentences are not necessary and abbreviations are appropriate. However, avoid them until you have a handle on how the abbreviations are used - they differ for each specialty, and are consistent within the medical office where you work.

The length of the note will differ for each specialty as well. Generally, surgical notes are short and medical notes are long. Remember that the medical assistant student's note will usually wind up being  more detailed than those of the more advanced staff. Students have less clinical judgment and experience, so they often give a more thorough report of what they observed.


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