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It was initially developed for physicians, who at the time, were the only health care providers allowed to write in a medical record. Today, it is widely adopted as a communication tool between inter-disciplinary healthcare providers as a way to document a patient’s progress. The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status. History of Present Illness, or HPI.
This describes the patient’s current condition in narrative form. The history or state of experienced symptoms are recorded in the patient’s own words. The mnemonic below refers to the information a physician should elicit before referring to the patient’s “old charts” or “old carts”. The objective section of the SOAP includes information that the healthcare provider observes or measures from the patient’s current presentation. Vital signs and measurements, such as weight. Results from laboratory and other diagnostic tests already completed. The assessment will also include possible and likely etiologies of the patient’s problem.
It is the patient’s progress since the last visit, and overall progress towards the patient’s goal from the physician’s perspective. This will include etiology and risk factors, assessments of the need for therapy, current therapy, and therapy options. The plan is what the health care provider will do to treat the patient’s concerns – such as ordering further labs, radiological work up, referrals given, procedures performed, medications given and education provided. The plan will also include goals of therapy and patient-specific drug and disease-state monitoring parameters. This should address each item of the differential diagnosis. For patients who have multiple health problems that are addressed in the SOAP note, a plan is developed for each problem and is numbered accordingly based on severity and urgency for therapy.
A note of what was discussed or advised with the patient as well as timings for further review or follow-up are generally included. Often the Assessment and Plan sections are grouped together. A very rough example follows for a patient being reviewed following an appendectomy. No further Chest Pain or Shortness of Breath. Abd Bowel sounds present, mild RLQ tenderness, less than yesterday. Follow-up with Cardiology within three days of discharge for stress testing as an out-patient. Prepare for discharge home tomorrow morning.