What Are SOAP Notes?
By Dava Stewart
SOAP notes do not have anything to do with cleanliness. The four letters are a mnemonic device, first used by Dr. Lawrence Weed in the 1960s. The format gained popularity with the medical community throughout the 1970s. The letters stand for:
- Subjective
- Objective
- Assessment
- Plan
SOAP notes provide a systemized way for healthcare providers to track and share information about patients’ conditions and progress.
With the rise of Electronic Medical Record (EMR) systems, SOAP notes are becoming more important than in the past. Chiropractic practices without EMR systems may have their own systems that would be difficult for people in other offices or specialties to understand.
Since there is not much use in sharing information that is incomprehensible or that takes too long to parse, SOAP notes are used by many different types of health care practices to provide a simple, standard method of recording information so that it may be located and accessed by a range of providers.
By adopting SOAP notes, patient records become standardized and thorough, with all facets of the patient’s condition, progression and treatment easily accessible and clearly spelled out. The four parts of a SOAP note include:
A subjective description of the patient’s condition. This section includes when the pain started and what it feels like (dull, sharp, etc.), along with any self-reported observations the patient makes. It is the patient’s description of the issue.
Any objective measurements that may be repeated. Vital signs are a good example of something that would be included in the objective section of a SOAP note. They can be taken at each visit and changes are measurable. Lab results, height, weight and many other specific, objective measurements are also examples.
A clear assessment. One of the biggest parts of any health care provider’s job is to provide an assessment, or diagnosis, of the patient’s problem. If applicable, several alternative diagnoses should be included. The assessment section of a SOAP note is important in a legal sense because it is a direct statement of the healthcare provider’s opinion, based on expertise, experience and the two previous sections.
A plan for treatment. After providing an assessment of the problem, a health care provider needs to offer a treatment plan. The plan section of the SOAP note clearly states what the DC is going to do during future visits in order to help the patient. This section is useful for the DC at the next visit, and to any other specialists who may see the patient in the meantime.
Any practice that is working toward proving meaningful use of an EMR will find that SOAP notes are an important part of the process. Most EMR software includes templates and formats for SOAP notes, so there is no need to reinvent the wheel when establishing their use in the office.
Most practitioners who implement the use of SOAP notes report that it improves workflow, and often, patient outcomes. Having a set method for reviewing the notes from a patient’s last visit makes the next visit quicker. Also, using a set format may allow the DC to see patterns more easily and clearly.
