What are soap notes?
Soap notes are a type of note-taking used in the medical field to record patient visits. The name “soap” stands for:
These are the 4 sections of any soap note. Each section of the soap note must be completed in order, and you should write your soap notes after, not during, sessions with patients.
What are the 4 sections of soap notes?
In the subjective section of your soap note format, you would ask the patient questions related to their problem or how they feel, such as:
- What symptoms are you experiencing?
- How long have you been experiencing these symptoms?
- What areas of your body are affected?
- Are you in pain? If so, how much?
- When is your condition worse? When is it better?
Now that you’ve learned how your patient describes their feelings, the objective section of your soap notes is where you write down observations from your own examination. This is important because it can serve to corroborate or contradict what the patient is saying. Sometimes you can even find things the patient was unaware of.
Taking the data gathered in both the subjective and objective sections, your assessment contains your diagnosis of the issue the patient is facing.
In the final part of your soap note, you will write down the plan for treating or curing your patient. Here, it is also important to include whether the patient needs any special care such as transfer to a different hospital, or whether the patient is allergic to any typical medications and thus cannot be treated with them.
Who uses soap notes?
Soap notes are used by doctors and medical professionals dealing with physical illnesses. Mental health specialists commonly use dap notes, where dap stands for data, assessment, and plan. This is because unlike general practitioners or similar doctors, mental health professionals do not deal with physical symptoms, so they don’t need to distinguish between subjective and objective data.
The key benefits of soap notes are that they help narrow down data gathering until only what is important is left, and soap notes which are completed electronically can be stored, shared, and referred to anytime over the course of treatment.