SOAP is an acronym for subject, objective, assessment, and plan, and acts as a progress report for the patient and lets the healthcare providers know what has or has not been done to heal the patient. A SOAP note to the inexperienced can seem very confusing and difficult to understand. However when you break them down they become very simple. A SOAP note is by definition a document used by nurses doctors and therapist along with other health counselors. It is universally formatted so that all health care providers use the same template therefore providing clear and accurate information incase the patient switched healthcare providers.
Step 1: Formatting Your Soap Note
Most hospitals systems have their own format for writing SOAP notes between offices, but all of them begin with patients name, date of service diagnosis, and procedure code (or steps of action). Following this all SOAP notes are broken into four sections based on the soap acronym Subject, Objective, Assessment, and Plan. Most Soap notes are configured in the format in figure 3 and are available online for even more help. Most soap notes include a figure of a human body, this is present to help accurately pinpoint the patients injury and to help practitioners accurately diagnose and prescribe the correct treatment to provide the patient. Lisa Schwartz gives the following tip on “how” to compose SOAP Notes: “Although SOAP Notes are normally short and sweet, they must also be thorough and complete.” (Schwartz) You must make sure all your information is clear and easily readable. In these instructions we will help you write an effective and properly formated soap note.