How To Write Great SOAP notes?

SOAP notes are the most effective way to communicate and document a patient’s symptoms, diagnosis, treatment plans, and other vital details concerning their health.

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What is a SOAP note and how does it work?

What is a SOAP note and how does it work?

SOAP notes are the most effective way to communicate and document a patient’s symptoms, diagnosis, treatment plans, and other important details concerning their health. They are a widely recognized note format that are easily understood by most healthcare practitioners and can be tailored to specific needs of your healthcare practice, regardless of your health discipline. SOAP progress notes ensure you remain HIPAA compliant, and because they may be used in legal cases, they need to be clear, concise, and document all essential details. 

SOAP notes cover four distinct sections concerning subjective and objective observations, as well as assessment and planning aspects. They cover required elements that go into logical medical reasoning and help organize patient data in a way that provides direction for your goals of alleviating patient pain and meeting client needs. Understanding SOAP notes can be difficult, which is why over 64% of healthcare practitioners choose to use business software to better implement them into their practices. Regardless of your choice, you can’t go wrong with learning more about their format and how they are, quite simply, the leading option for documenting patient progress.

How to write the four parts of a SOAP note?

There are four main parts to a SOAP note, which include subjective, objective, assessment, and plan sections. These aspects serve as the backbone of SOAP notes, and are what defines and shapes their structure. Whether or not you use software with embedded clinical note templates, it is important to understand the four core components. 

  • Subjective (S) - This section centers around the experience of the patient, and facilitates understanding of subjective insight. Subjective notes, including word for word statements, assist with portraying the patient's sentiments, indications, and progress towards treatment objectives.
  • Objective (O) ​- Alludes to the specialist's perceptions concerning the patient's clinical data, assessments, tests, x-rays, verifiable data, prescriptions, and medication, as well as important physiological functions. It is reality-based, liberated from any clinician impressions.
  • Assessment (A) - This sums up the abstract and objective segments and is a directional segment that spotlights progress towards a treatment plan. It assesses how the patient is doing in their present status and notes their finding all things considered and any changes. These are then implemented into the following plan. 
  • Plan (P) - The last segment of SOAP notes is to infer a treatment plan that is dependent on the patient's past perceptions and current treatment plan or state. This is where a course of action, with quantifiable objectives explicitly recorded, is finalized to treat the patient.
How to write the four parts of a SOAP note?
6 effective tips to write great SOAP notes

6 effective tips to write great SOAP notes

While following the SOAP note structure is relatively straightforward, there are some aspects you should include to elevate the quality of their content. This way, you can ensure you are meeting legal and professional standards, whilst providing a high level of care for your patients. 

  • Write professionally - Avoiding slang, abbreviations, and colloquialisms make your writing easier to understand by other healthcare professionals who review and assess your notes. It also conveys the patient's experience of mental health with greater clarity and allows your notes to come from a more authoritative nature. Your writing also reflects a higher degree of medical reasoning if written from a professional perspective, and emphasizes good business practices.
  • Stay neutral - Refrain from injecting personal judgments, biases, assumptions, and interpretations of information within the subjective and objective sections. This is where you convey the client's experience with quotes and relay relevant medical data, and it should remain distant from your personal opinion. Professional opinion may be used sparingly, but it is best to stay neutral for legal purposes and to ensure your notes are high-quality. Failing to do so could lead to misinformation and ineffective treatment plans that do not address patient symptoms and problems. 
  • Quality over quantity - SOAP notes should not exceed two pages in length, and they should be concise and convey points quickly and effectively. Because other medical professionals will be reviewing your content, information must be relayed efficiently so they can quickly clarify and pinpoint the healthcare issues that need treating. It also takes time to write progress notes, so keeping them short and to the point increases productivity.  
  • Distinguish symptoms and signs  - Symptoms should be outlined in the subjective section, and signs of symptoms should be outlined in the objective section. You mustn't misconstrue these components, as, despite their immediate relation, they are actually quite distinct. 
  • Timing is everything - Write notes shortly after you have seen the patient, as waiting too long can result in you forgetting important information. This can be especially critical when it comes to establishing treatment plans for patients, as they may not address the issues that need recognition. 
  • Ensure legibility - Your notes should be able to be understood from a grammar perspective. They need to be clear with the right medical terms referenced and spelled correctly, and if the notes are handwritten, they need to be legible. Electronic SOAP notes are a great way to ensure legibility at all times and avoid any misdiagnosis that can occur.

3 common mistakes to avoid while writing SOAP notes

To ensure that your notes are effective and accurately represent the patient you are assessing, it is important to keep these common pitfalls in mind. This way, you can avoid making the same mistakes, and save yourself any time and energy used in the correction process.

  • Don’t make general statements - General statements can often fall into impressions or interpretations when it comes to writing objective sections, so it is best to avoid them altogether. This is especially crucial in the plan section, as general statements can blanket the patient’s experience, and prevent the synthesis of productive treatment plans with specific goals. 
  • Avoid repetition - It can be very easy to repeat yourself in the assessment section, as you’re referencing subjective and objective information. However, repetition should always be avoided. Work towards combining the two sections regarding the current progress of the client, and analyze the data to determine what adjustments need to be made.
  • Always include sourced opinions - When recording client quotes or opinions, you always need to source them within their statements. The same goes for third-party members such as family or friends, as they also need to be noted for easier quotation attribution. Furthermore, it provides, and proves, an assessment based on factual information gathered from the session. 
  • Avoid rewriting - If you need to make any changes, avoid rewriting, and instead, you should note any amendments. These should be recorded in the assessment plan, and it will save you an immense amount of time. 

Take home message

In light of its easy-to-use design, which addresses vital parts of clinical documentation, SOAP notes are broadly utilized and perceived in the medical care industry. They are an excellent strategy that aids clear organization and are simple to decipher by other medical service experts because of their professional methodology. The cycle from perception to the definition of a treatment plan is profoundly straightforward and offers huge worth to practices that utilize them. It allows for consistency in the case of law and ethics with its adaptable design and is an ideal choice in medical care businesses across the board.

Numerous platforms, like Carepatron, incorporate SOAP note layouts into their work process, which makes changing to this widespread documentation strategy even more valuable. Implemented SOAP layouts mean your practice can consistently incorporate them into your clinical space, with a clean user interface guaranteeing a simple learning experience. Carepatron is an excellent service for diving into SOAP notes, as well as for providing the best care to your patients.

Further reading:

3 common mistakes to avoid while writing SOAP notes

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