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Nota SOAP en fisioterapia: Explicación, guía y ejemplos

Utiliza las notas SOAP para agilizar y estandarizar la información obtenida de un paciente. Como fisioterapeuta, aprender a escribir y utilizar una nota SOAP te beneficiará profesionalmente de muchas maneras.

Soap notes are a tool used by healthcare professionals to assess a patient’s condition after a session. If a particular patient presents a challenge or has a complex case, writing a soap note can help with record-keeping and treatment. The soap note format allows doctors to build robust patient profiles.

Table of contents

1. What is a soap note?

2. What are the components of a soap note?

2.1. Subjective

2.2. Objective

2.3. Assessment

2.4. Plan

3. What are the advantages of a soap note?

4. What are the do’s and don’ts when writing a soap note?

5. What is the difference between a soap note and a dap note?

What Is a soap note?

A soap note is a way of documenting information used by healthcare practitioners to create accurate and easy-to-understand information regarding a patient’s or client’s visit. It’s a documentation style that allows medical professionals to take records so that it will be easy for them to reference them later. Sometimes, doctors are faced with complex patients and sophisticated situations. When this happens, it’s possible to lose track of priorities and goals. But the soap note format keeps you adherent to an organized system and allows you to collect insight on a patient’s case no matter their issue.

After observing a need to create accurate documentation of a patient’s encounter, Dr. Lawrence Weed created soap notes as a four-staged system that medical or healthcare practitioners can use to properly record important details while attending to a patient. The four stages of the process are reflected in the name soap note, which stands for subjective, objective, assessment, plan. This easy-to-grab soap note meaning is intended to remind health practitioners of the work involved in drafting soap notes.

Writing a soap note allows medical professionals to send patients copies of their records electronically or manually in case they ask. Keeping organized patient records also helps you prepare for their next visit. When the same patient visits again, you can use your soap note to facilitate the session.

Soap notes are commonly stored in electronic medical records (EMI), so the chances of them getting lost or misplaced are slim. Doctors or nurses can always refer back to an EMI and share records with other professionals. Even if the patient visits a new hospital, if they have a previous health record that was written as a soap note, that record can be shared with the hospital.

Going over a patient chart

What are the components of a soap note?

As stated, the name soap note indicates the four steps of writing one. Following the soap format leads to systematically-created and easy-to-read documentation. They also help medical providers remember the most important things to note about patient visits. The four steps in a soap note example are:

  • Subjective
  • Objective
  • Assessment
  • Plan

To get the most out of your soap notes, you’ll want to complete each of these steps in order. Understanding each stage of the process will give you a better grasp of the meaning of soap notes.

Subjective

This is the first step to writing an effective soap note. The ‘subjective’ part of a soap note refers to the views and feelings condition of your patient. Ordinarily, when a patient walks into a hospital with a health problem, the doctor asks questions such as ”how do you feel?” or “where is the pain?”. These preliminary questions about how patients feel are the focus of the subjective stage. The specific information recorded is:

  • Chief complaints (CC): This refers to your patient’s personal complaints, including any symptoms the patient is currently experiencing (e.g., headache, eye ache, high body temperature). It is usually the main reason for a patient’s visit. It also gives an insight into what the rest of the soap note will be about. A well-written soap note depends on proper or accurate documentation of patient complaints.
  • History of present illness: Often shortened to HPI, this section usually begins with the client’s age, sex, and the reason for the visit. Here, the doctor or nurse notes the history of and other details concerning the client’s chief complaint. HPI sections are typically organized with the mnemonic «OLDCARTS «. It stands for:
    • Onset: When did the patient begin experiencing the CC?
    • Location: Where is the CC located?
    • Duration: How long has the CC been present?
    • Characterization: How does the client describe the CC?
    • Alleviating & aggravating factors: What makes the CC better and what makes it worse?
    • Radiation: Does the location of the CC change?
    • Temporal Factor: does the CC get better or worse at different times of the day?
    • Severity: on a scale of 1-10, how severe is the CC?
  • Patient’s history: This area includes the patient’s medical, surgical, family, and social history. Patient histories are important in healthcare decision-making.
  • Review of systems (ROS): During a patient’s and doctor’s encounter, you may observe symptoms the patient has not mentioned. This is the purpose of an ROS section. For instance, questions about a patient’s general, gastrointestinal, or musculoskeletal health may provide new insights.
  • Allergies & current medication: It’s important to note any record of the patient’s allergies and medications because this can also impact the patient’s CC. Allergies can also affect what kinds of treatments or drugs are prescribed to the patient.

Objective

This section of a soap note template records the objective signs discovered during the patient’s visit. Healthcare practitioners usually run tests, examinations, or visual inspections. The objective section of a soap note includes data obtained from vital signs, diagnostic data, laboratory data, physical exam findings, imaging results from scans, and more.

Assessment

After recording subjective and objective data, you will analyze both and arrive at a diagnosis. This diagnosis is discovered by assessing all gathered information. All information relating to the diagnosis is recorded in order of importance. The assessment stage might also include any other problem that patients face due to their current health condition.

Plan

This section details what is needed to cure or treat the patient. It helps medical professionals stay on top of their treatment plans. Apart from medication, surgery, or consistent observation, it can also include additional steps that need to be taken to treat the patient, such as transfer to another medical institution or special treatment sessions like therapy and yoga.

The intuitive soap note format makes communication with patients efficient and effective. Subjective and objective data are particularly important to record in your soap notes. Make sure it is easy to read and eliminate unnecessary information.

What are the advantages of a soap note?

Soap notes are very effective ways to maintain a patient’s medical record. Not only isCombining easy note-taking with an intuitive format, soap notes eliminate information that isn’t necessary or important. Soap notes benefit medical practitioners because:

    • They allow for effective communication: In some cases, getting information from patients can be difficult, especially if you’re dealing with a patient who isn’t very learned. But following a soap note example guides you through communicating effectively with patients. They make sure you know what questions to ask and what to record in your report sheet.
    • Soap notes boost morale: Using soap notes can help make medical professionals feel more confident dealing with patients. If you as a doctor aren’t sure of what you’re supposed to do while attending to a certain patient, a soap note provides you a way to keep control of the entire session.
    • They allow for easy and seamless documentation: In case you’re not sure how to document your time with a patient, the soap note format gives you a structure to follow. The four stages are a clear and comprehensive way to orient your record-keeping
    • They provide points of reference: After using soap notes with a particular client, doctors or nurses can always refer back to them during future visits. Soap notes are a reliable point of reference because every important piece of information concerning a patient’s health is automatically stored.

A doctor and her client communicating

What are the do’s and don’ts when writing a soap note?

Now that you know what a soap note is, it’s important that you also know how to write them correctly. To make sure they are the best they can be:

      • Do not write soap notes while you’re in the session with a client or patient. Instead, take personal notes that will help you write the soap note later.
      • After seeing a patient, do not wait too long before you start writing the soap note.
      • Avoid using phrases and grammar that are informal and not descriptive. For example, instead of saying, » the client had a wonderful time,» you can say, «the client smiled and laughed a lot during the session.» This is more descriptive and formal.
      • Avoid using too many words to describe anything when fewer words can be used.
      • Do not emphasize too much positivity or negativity while taking down notes.
      • Do not make any subjective statements concerning the client without evidence.
      • While taking down notes, avoid being judgemental and never jump to conclusions without thorough analysis.
      • Avoid pronoun confusion, and make sure that every subject of an action is clear.
      • Avoid using slang, poor grammar, or unfamiliar abbreviations.
      • Do not use vague words such as ‘seem’ or ‘may.’

Keep your soap notes accurate, easy-to-understand, and effective by:

      • Making your statements concise and precise.
      • Maintaining a professional and formal voice while taking down notes.
      • Write soap notes when you won’t be distracted by anything.
      • Using culturally sensitive language.
      • Always proofreading your notes.
      • Quoting your patient exactly when including a quote.

What is the difference between a soap note and a dap note?

When researching soap notes, you may also come across the term dap note. Dap notes are used explicitly by mental health professionals; and just like the meaning of soap notes is in the name, dap stands for:

      1. Data
      2. Assessment
      3. Plan

Just like soap notes, it is important to do each phase of a dap note in order. Dap notes are more or less shorter versions of soap notes – the data stage corresponds to the subjective stage, and there is no objective stage because mental health professionals do not deal with physical symptoms. Then, the assessment and plan stages are the same.

A dap note example would include:

      • The data concerning client information, session topics, what was said about those topics, and the patient’s reactions to what was said.
      • An assessment of how the session progressed overall, given all the information recorded in the data stage.
      • Strategies for future sessions based on the outcome of the current one, including what problems or sensitive topics have been identified and how those will be approached.

Can any healthcare professional use dap notes? Dap notes tend to be most useful to therapists because of the lack of distinction between objective and subjective data. Since mental health professionals don’t deal with physical symptoms, they record every observation equally. That’s why every example of a dap note will be geared towards use in mental health.

By the same logic, soap notes are ideal for doctors in other fields. You can easily create and refer to your soap notes with Lumiform, a paperless form and inspection platform. Find a ready-made soap note example template, or create your own in minutes.

A diagnosis being delivered

 
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