What is a SOAP note? The Subjective, Objective, Assessment and Plan (SOAP) note is an acronym representing a widely used method of documentation for healthcare providers. The SOAP note is a way for healthcare workers to document in a structured and organized way. AGAIN please do research if needed. I have provided a nursing SOAP note example and the grading rubric below in attachments. Assignment MUST include ALL that’s on the example of the SOAP note attached here. What to write in each section: This is an example of what should go under each area. This is not a total list, just an example. Again please see soap note example and look up what should go under each area. Chief Complaint: ( why is the patient here in clinic today?) History of Present Illness: when did this problems start/How long has the problem been going on? what are their symptoms?) Past Med History: Any problems with their health/ any diseases or medical issues such as high blood pressure, diabetes etc. if so, how long have they had it/ when were they diagnosed? are they under a doctors care for problem? are they on any medications for problem?) Past Surgical history: (any surgeries? if so, when? and why?) Family History of medical problems: ( Include 3 generations; mother, father, siblings, paternal grandmother/grandfather, Maternal grandmother/grandfather. if so, what did they have, if they’ve died what from and when/what age were they at the time of death?) Social History: (Friends, work, activities, hobbies, living situations, relationships etc.) Medications: ( any medications they’re on. why they are on the medication/ for what reason? what is the dosage? how often do they take it? how often is it prescribed? who prescribed it? if they are not taking prescribed medication that a doctor prescribed, why not?) Allergies: ( any allergies to medication, food, pets, dander, environmental allergies, etc. What happens when they are exposed to allergen/what happens to them? do they require an epi-pen for allergy? if so, do they carry the epi-pen on them? when were they diagnosed with this allergy/age?) Tobacco, Alcohol, Drugs, Substances: If they do any drugs/alcohol/tobacco/substances how much do they do (quantity)? how often do they do it? how do they perceive it? do their friends do any of these? Is there any of this going on in their home?) (ROS) Review of systems: (LOOK UP/SEE SOAP note example) Be thorough, but only document what is relevant to the patients case) ROS Consist of examination of the list below: Examination of: General appearance: (Including vital signs) Eyes: Ears, Nose, Mouth, Throat: Cardiovascular: Respiratory: Gastrointestinal: Genitourinary: Musculoskeletal: Skin and/or breasts: Neurological: Psychiatric: Endocrine: Hematologic/Lymphatic: Allergic/Immunologic
A SOAP note is a method of documentation used by healthcare providers, including nurses and physicians, to document patient care in a structured and organized way. The acronym SOAP stands for Subjective, Objective, Assessment, and Plan, which represents the four sections of the note.
The subjective section of the SOAP note includes information gathered from the patient, such as the chief complaint, history of present illness, and social history. This section is subjective because it relies on the patient’s perception and interpretation of their symptoms and history.
The objective section of the SOAP note includes factual information gathered from the healthcare provider’s observations and measurements, such as vital signs, physical examination findings, and laboratory results. This section is objective because it is based on factual information rather than the patient’s perception.
The assessment section of the SOAP note includes the healthcare provider’s diagnosis or impression of the patient’s condition, based on the subjective and objective information gathered. This section should include the provider’s interpretation of the patient’s symptoms, the medical history, and the physical examination findings.
The plan section of the SOAP note includes the healthcare provider’s plan for treating the patient, including any medications prescribed, treatments recommended, or referrals to specialists. This section should also include any follow-up appointments or tests that are needed.
In summary, a SOAP note is a standardized method of documentation used by healthcare providers to document patient care in a structured and organized way. It includes the subjective and objective information gathered, the healthcare provider’s assessment of the patient’s condition, and the plan for treatment.
