A SOAP note is a documentation method employed by health care providers to create a patient’s chart. There are four parts of a SOAP note: ‘Subjective, Objective, Assessment, and Plan.
Describes the patient’s current condition in narrative form. This section usually includes the patient’s chief complaint, or reason why they came to the physician.
- Onset (when and mechanism of injury – if applicable)
- Chronology (better or worse since onset, episodic, variable, constant, etc.)
- Quality (sharp, dull, etc.)
- Severity (usually a pain rating)
- Modifying factors (what aggravates/reduces the complaint – activities, postures, drugs, etc.)
- Additional symptoms (un/related or significant symptoms to the chief complaint)
- Treatment (has the patient seen another provider for this symptom?)
Documents objective, repeatable, and traceable facts about the patient’s status.
- Vital signs
- Findings from physical examinations, such as posture, bruising, and abnormalities
- Results from laboratory
- Measurements, such as age and weight of the patient
The Physician’s medical diagnoses for the medical visit on the given date of a note written.
This describes what the health care provider will do to treat the patient – ordering labs, referrals, procedures performed, medications prescribed, etc.
So many aspects of modern health care are derived from the SOAP note. Everything done on an EMR system, all the objectives OCR has in mind for Meaningful Use, every specialist that can work on their iPad – all are built upon the SOAP methodology.
The SOAP note was first generated by Dr. Lawrence Weed, MD in the 1970’s, under the acronym POMR (‘Problem Oriented Medical Record’). At the time, there was not an objective method of documentation, which lead to physicians making unscientific decisions about patient treatment.
SOAP notes gave physicians rigor, structure, and a way for practices to communicate with each other. In the early 1970’s, the adopters of SOAP notes were able to retrieve all patient records for a given medical problem – something EMR’s do even better today.
Before EMR software, providers had trouble accessing needed charts. Before standardized SOAP notes, providers communicated with each other in unstructured formats, leaving patient care up to great chance.
EMRSoap uses a rigorous methodology similar to SOAP-notes. When deciding how to advance your practice using Health IT, we first address your Subjective needs, like how your practice prefers to use technology throughout its practice, and what you want to change. Then, we assess your Objective needs, looking at your practice’s security and compliance. Finally, we make our own Assessment of what you should do, and develop a Plan moving forward.
Contact us today to learn more about our methodology, and how you can use Health IT to advance your practice.