GAUTHAM COLLEGE OF PHARMACY

The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by health care providers to write out notes in apatient's chart, along with other common formats, such as the admission note. Documenting patient encounters in the medical record is an integral part of practice workflow starting with patient appointment scheduling, to writing out notes, to medical billing.

 

The SOAP note originated from the Problem Oriented Medical Record (POMR), developed byDr. Lawrence Weed. 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.

 

SOAP notes are now commonly found in electronic medical records (EMR) and are used by providers of various backgrounds. Prehospital care providers such as EMTs may use the same format to communicate patient information to emergency department clinicians. Physicians, Physician Assistants, Nurse Practitioners, Pharmacists, Podiatrists, Chiropractors, Physical Therapists, Certified Athletic Trainers (ATC), Sports Therapists, Occupational Therapists, among other providers use this format for the patient's initial visit and to monitor progress during follow-up care.

 

SOAP notes are a highly structured format for documenting the progress of a patient during treatment and is only one of many possible formats that could be used by a health professional. They are entered in the patients medical record by healthcare professionals to communicate information to other providers of care, to provide evidence of patient contact and to inform the Clinical Reasoning process.

 

SOAP is an acronym for:

• Subjective - What the patient says about the problem / intervention.

• Objective - The therapists objective observations and treatment interventions (e.g. ROM, Outcome Measures)

• Assessment - The therapists analysis of the various components of the assessment.

• Plan - How the treatment will be developed to the reach the goals or objectives.

 

History

 

SOAP notes were developed by Dr. Lawrence Weed in the 1960's at the University of Vermont as part of the Problem-orientated medical record (POMR). Each SOAP note would be associated with one of the problems identified by the primary physician, and so formed only one part of the documentation process. However, various disciplines began using only the "SOAP" aspect of the format, the "POMR" was not as widely adopted and the two are no longer related (Quinn & Gordon, 2003).

 

Advantages and disadvantages

Quinn and Gordon (2003) suggest that the major advantage of the SOAP documentation format is it's widespread adoption, leading to general familiarity with the concept within the field of healthcare. It also emphasises clear and well-organised documentation of findings with a natural progression from collection of relevant information to the assessment to the plan on how to proceed.

 

However, the format has also been accused of encouraging documentation that is too concise, overuse of abbreviations and acronyms and that it is sometimes difficult for non-professionals to decipher. Delitto and Snyder-Mackler (1995) have also suggested that a sequential, rather than integrative approach to clinical reasoning is encouraged, as there is tendency by the health professional to merely collect information and not assess it. They feel that the emphasis on the problem-orientated approach to documentation is misplaced and that it is not conducive to clinical decision-making.

 

One major difficulty with SOAP notes for physiotherapists, is the lack of guidance on how to address functional outcomes or goals. Having said that, the format is not so rigid that it cannot be adapted to take this into account.

 

Writing a SOAP note

 

While documentation is a fundamental component of patient care, it is often a neglected one, with therapists reverting to non-specific, overly brief descriptions that are vague to the point of being meaningless. There is no policy that dictates the length and detail of each entry, only that it is dependent on the nature of each specific encounter and that it should contain all the relevant information. However, the American Physical Therapy Association does provide the following guidance on what information should be included (Quinn & Gordon, 2003):

 

• Self-report of the patient

• Details of the specific intervention provided

• Equipment used

• Changes in patient status

• Complications or adverse reactions

• Factors that change the intervention

• Progression towards stated goals

• Communication with other providers of care, the patient and their family\

Bear in mind that your report will be read at some point by another health professional, either during the current intervention, or in several years time. Therefore, it is your professional responsibility to make sure that it is well-written.