How To Write Soap Notes: The Complete Guide

by Nicky Liedtke | October 12, 2022 | Reading time: 8 minutes

What Is a Soap Note

A soap note is a method of documentation 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 often faced with complex patients and sophisticated situations. In this case, it's possible to lose track of priorities and goals while attending to a patient. But a soap note makes sure that you follow an organized system while documenting your encounter with a patient regardless of the issue they're faced with.

Following the need to create accurate documentation of a patient's encounter, Dr. Lawrence Weed created a four-staged system that medical or healthcare practitioners can use to properly take notes of important details while attending to a patient. The four stages are embedded in the name soap note which stands for subjective, objective, assessment, plan. Medical and health practitioners are encouraged to take important notes in this format to make it easy for them to understand how to attend to each patient.

A soap note is a very valuable piece of information for doctors and even patients. Patients can receive a copy of their records electronically or manually as evidence of their health records in case they need it. Soap notes can also be beneficial to healthcare providers because having a patient health record in a very organized way prepares you completely for their next visit. When the same patient visits again, you can take a look at their record, which you've taken before, in an organized manner and use it to guide your next encounter with them.

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 a patient health record and make better decisions while treating them again. Even if the patient is new in the hospital, if they have a previous health record that was written using soap notes techniques, it can be presented to the healthcare practitioners of the new hospital. This will help provide necessary information to enhance better decision-making while dealing with the client.

In this article, you will learn about:

1. The components of a soap note

2. The advantages of a soap note

3. The do's and don'ts when writing a soap note

What Are The Components of a Soap Note?

A soap note's components further translate to the different areas that a soap note targets. These areas are what healthcare providers adhere to when creating a systematic and easy-to-read documentation format. They also guide providers on the most important things to note while attending to clients. A soap note has four components abbreviated into the word "SOAP." They are:

• Subjective
• Objective
• Assessment
• Plan

To have a detailed insight into the question, what is a soap note? You'll have to understand the meaning of the abovementioned components and what they entail. A closer look into these components will help you understand the purpose of a soap note and how it is used. Let's get to it.

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 the subject in a medical encounter. The subject refers to the patient or client who has booked a medical appointment. Ordinarily, when a patient walks into a hospital, looking to see the doctor concerning a certain health problem, the doctor initially communicates with the patient to gain necessary information that will prove helpful throughout the entire session. This is simply the focus of a soap note's 'subjective' section. In this section, the following are documented:

• Chief Complaints (CC): This refers to the personal complaints made by the client. This could be any symptoms or constant the patient is currently experiencing, e.g., headache, eye ache, high body temperature, e.t.c. It is usually the main reason for the client's visit. It also gives an insight into what the rest of the soap note will be about. A soap note cannot be constructed in the first place without a proper or accurate document of the patient's message. For instance, a doctor or nurse has to know what is wrong with a client before going further with the session. And the first step to knowing this is listening to the patient to what he/she has to say.
• History of Present Illness: Often shortened to HPI, this section usually begins with the client's age, sex, and the reason for the visit. This section is where the doctor or nurse notes the history and more details concerning the client's chief complaint. The mnemonic "OLDCARTS "is often used to organize this subsection. It includes;
  • Onset: When the client started experiencing the CC, e.g., 'beginning of the month'
  • Location: Where the CC is located, e.g., 'ache in the eye and head.'
  • Duration: How long the CC has been happening, e.g., 'headache has been happening for two months.
  • Characterization: How does the client describe the CC e.g, 'the headache gets severe every night'.
  • Alleviating & Aggravating Factors: What makes the CC better and worse, e.g., 'exercise worsens the headache and sleeping reduces it.'
  • Radiation: Does the location of the CC change? e.g., 'does the headache transverse to general body ache?'
  • 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 is going to contain the patient's medical, surgical, family, and social history. Collecting information based on the highlighted factor is important for the healthcare provider involved.
• Review of Systems (ROS): During a patient's and doctor's encounter, some symptoms that the patient hasn't said can be uncovered through a series of questions. This is what the ROS section focuses on. For instance, patients can be asked questions concerning their general health, gastrointestinal, or musculoskeletal condition to help uncover obscure systems that can help providers make smarter decisions.
• Allergies & Current Medication: A section is also provided to note any record of the patient's allergies and medications because this can also impact the patient's CC in one way or the other. What the patient is allergic to 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 encounter. This means that all other signs of the patient's complaint will be figured out. Healthcare practitioners usually run tests, examinations, or visual inspections. This section includes data that is obtained from vital signs, diagnostic data, laboratory data, physical exam findings, imaging results from scans, etc.

Assessment

After getting the subjective and objective data down, the medical professional analyzes both and arrives at a diagnosis. The diagnosis, which is the actual problem or issue that the patient complains about, is discovered through proper assessment of every information that has been gathered for the patient's encounter. The information concerning the diagnosis is then recorded in this section in order of importance. It might also include any other problem that patients are open to due to their current health condition.

Plan

This section includes the steps it would take to cure or treat the patient. This section helps medical professionals stay on track with what needs to be done to treat the patient. Apart from medication or surgery or consistent observation, it can also include additional steps that need to be taken to treat the patient. For example, suppose the patient needs to be transferred to another medical institution or offered special treatment sessions like therapy, yoga, consultations, and health education. In that case, it should be included in this section.

It's paramount that healthcare providers follow this systematic and universal format to make communication with patients efficient and effective. Most importantly, the subjective and objective data must be captured accurately for the SOAP note to be effective. The information captured in both sections also needs to be easy to read and eliminate unnecessary information.

What Are The Advantages of a Soap Note?

Soap notes are very effective when taking notes of and maintaining a patient's medical record. Not only is it useful for note-taking, but its documentation style is also constructed in a way that is easy to read and understand. And to top it off, it allows for simple and precise note-taking while eliminating the need to put down any information that isn't necessary or important. Using soap notes is very beneficial to healthcare providers in the following ways:

• It allows for effective communication: In some cases, communicating with a patient to derive information can be burdensome, especially if you're dealing with a patient who isn't very learned. But with a soap note, you'll be guided on how to communicate effectively with the patient with the sections available to you. Soap note guides you on what to talk to the patient about and what to record in the report sheet during the patient's reply.
• It boosts courage and bolsters morale: Using soap notes can help to boost the morale and courage of medical professionals whenever dealing with any patient. If you as a doctor aren't sure of what you're supposed to do while attending to a certain patient, a soap note can restore your confidence or morale, enabling you to gain control of the entire session and handle it well.
• It allows for easy and seamless documentation: In case you're not sure how to document your time with a patient, a soap note can guide you on how to structure your note. With the four stages systematic note-taking method, medical practitioners can seamlessly document their encounter with a client, notwithstanding the nature of the visit.
• It serves as a point of reference: After a successful note-taking with a soap note for a particular client, doctors or nurses can always refer back to the previous record whenever the same person visits again. They can use it to better understand the patient's condition if they have forgotten. Soap notes are a reliable point of reference because every important piece of information concerning a patient's health is automatically stored.



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What Are The Do's and Don'ts When Writing A Soap Note?




Soap notes can either be effective or ineffective depending on how you go about writing them. To ensure that you're doing it right, ensure not to do the following:



• 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 the session with a client, 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 any 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 slangs, poor grammar or odd abbreviations.
• Do not make use of tentative words such as 'seem' or 'may.'



To ensure that your soap note is accurate, easy-to-understand, and effective, ensure that you do the following:



• Make your statements concise and precise.
• Always maintain a professional and formal voice while taking down notes.
• Write soap notes only at the most appropriate time when you won't be distracted by anything.
• Ensure to write legibly.
• Ensure to use language that is culturally sensitive.
• Always proofread your notes.
• When quoting your client, ensure to quote the precise words stated by your client.




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Nicky Liedtke

Nicky is a content writer and researcher for Lumiform. With her content writing and copywriting experience, she creates high-quality content across a variety of relevant topics. She aims to promote workplace safety, sustainable operational excellence, and continuous improvement in her articles. She is passionate about communicating how technology can be used to have a positive impact on the environment and helping organizations reduce paper waste and achieve their business goals.