Modernize and streamline your patient assessments by digitally creating a SOAP format using an example.
Nurses can use this SOAP note template to collect patient’s information for admission purposes.Download template
Work with this pediatric SOAP note to document the child patient’s condition.Download template
The SOAP format is a documentation method used in the medical field. Doctors, nurses, therapists, sports trainers and consultants use this type of notes to record and assess the condition of a patient. The acronym "SOAP" stands for the English terms: Subjective, Objective, Aassessment, Plan. This type of recording is one way of structuring the anamnesis sheet or medical record.
The SOAP note format can be well designed in the form of a checklist for data collection. This ensures that all information about the patient and his clinical picture is recorded. Medical personnel also use the SOAP documentation to collect and exchange patient information over a longer period of time.
A SOAP note format consists of four main parts, which serve to improve the evaluation and standardize the documentation:
Subjective: Subjective complaints of the patient - what he/she tells you. (anamnesis)
Objective: Objective findings from physical examinations and from laboratory tests - what you see.
Assessment: Analysis of medical history and diagnoses, as well as their evaluation and summary - what do you think is going on?
Planning: Planning of therapies and further examinations - what you will do about it.
SOAP notes with a template, enables medical staff to provide clear and precise documentation of patient information. This way of recording helps those involved to get a precise overview and a better understanding of the patient's concerns and needs.
Below you will find a short guide on how to work effectively with a SOAP note template:
This section in the SOAP note checklist refers to all information that is communicated orally by the patient. Write down the patient's complete statement and insert quotations. The patient's medical history, surgical history, and social history should also be noted as it may help to identify or narrow down the possible causes. It can be written down as follows:
Subjective: Patient condition: "My throat and my body aches. I have a fever. It's been like this for four days.
The patient is a 28-year-old man. Before that, the patient says he had a cold and then the whooping cough developed into the actual symptoms.
This section consists of observations made by medical professionals. Study the patient's general appearance and also take into account vital signs (e.g. temperature, blood pressure, etc.). If specific tests have been performed, the results should be reported. Using the previous example, we can describe the objective section in the SOAP note template as follows:
Objective: Vital signs correspond to a temperature of 39°, BP of 130/80. The patient shows rashes, swollen lymph nodes and a red throat with white spots.
This section describes the diagnosis or condition of the patient. The evaluation is based on the results given in the subjective and objective parts. This section also includes ordered diagnostic tests (e.g. x-rays, blood count) and referral to other specialists. With the example chosen, the assessment would look like this:
Assessment: This is a 28-year-old man with a history including a cold and whooping cough. He reports sore throat, fever and fatigue. The clinical examination suggests bacterial pharyngitis due to swollen lymph nodes and the presence of white patches in the throat.
2. High fever (caused by pharyngitis)
This section of the SOAP note template deals with the patient's illness identified in the previous section. A treatment plan is worked out, specifying the required medication, therapies and operations. This section is also used for patient education such as lifestyle changes (e.g. dietary restrictions, no extreme sports, etc.). Additional tests and follow-up consultations are also specified. With the selected example, the following plan can be written as SOAP notes:
Acetaminophen - take every 6 hours x 5 days
Penicillin (500mg) - once daily for 5 days
No labs or consultations. After 5 days follow-up if symptoms persist or worsen. Drink plenty of water and take vitamin C.
Medical staff can use the Lumiform tool to digitally fill out their SOAP note template This dramatically improves the quality and continuity of patient care by providing the following benefits of a digital solution:
To help you get started with a digital SOAP note checklist, we have selected the best templates, which you can download free of charge and customize according to your needs. Our simple form construction kit also offers you the possibility to quickly and easily create your own templates for your SOAP notes.