SOAP notes are used by doctors, nurses, and other medical professionals to record patient interactions. Following a SOAP checklist improves the quality of your records by standardizing your approach to patient interviews, so you’re always able to get crucial information and provide the best care.
SOAP is an acronym made from the 4 section of the SOAP note process. These steps are:
- Subjective: where you ask questions about how your patient feels
- Objective: where you record observations made based on what the patient tells you
- Assessment: taking the data from the previous sections and diagnosing the patient
- Plan: detailing how the treatment will proceed
Writing a useful and accurate SOAP note is all about asking good questions, which is why using a SOAP checklist to guide you is so important. Sticking to a concrete SOAP format and identifying the necessary information beforehand both saves time and makes interactions less stressful for patients.
This video walks you through creating your own SOAP notes including what sorts of questions to ask during each section of the SOAP process.
