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Writing A SOAP Note

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Paola Murillo
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27 views9 pages

Writing A SOAP Note

Uploaded by

Paola Murillo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Writing a SOAP note

SOAP notes are intended to capture specific information about a


patient and certain aspects of the session. SOAP notes include a
statement about relevant client symptoms or status (Subjective),
observable, quantifiable, and measurable data (Objective), analysis of
the information given by the client and by lab results (Assessment), and
an outline of the next course of action (Planning). All SOAP notes
should be kept in a patient’s medical record.
(S)Subjective
• Statement about relevant patient behavior or status.
• This is where you as the clinician enter information regarding the client’s
chief complaint, presenting problem, and any other relevant information
You might also include personal or medical issues that may impact or
influence the client’s day-to-day routine.
• Contains a complete account of the client’s description of symptoms and
the progress from the last encounter

• When making subjective statements, include pertinent evidence. For


example: “Client appears nervous as evidenced by fidgeting of hands, not
maintaining eye-contact, and shortness of breath during our session”.
(O)Objective
• Observable, quantifiable, and measurable data.
This part of the note includes factual documentation about the client including a client’s diagnosis, behavioral and/or physical signs, appearance,
orientation, and mood/affect. How the client presented themselves (affect, behavior, eye-contact, nervousness, talkativeness) based on your
observations:
• Verbal/non-verbal
• Body posture
• Affect when discussing certain topics or issues

Content to include:
• Physical, interpersonal, and psychological observations, General appearance, Client’s ability to participate in the session, Client’s responses to the
process, Written materials such as reports from other providers, psychological tests, or medical records can be included here (if applicable)
• Examples:
• Jon is alert: oriented to time and place & he’s actively participating during today’s session as indicated by positive responses and prompt replies.
• Jon displays a mostly flat/blunted affect, hygiene is below baseline. He takes several seconds to respond to questions I ask him during the session.

Content to avoid:
• General statements without supporting data, Avoid assumptive statements pertaining to behavior, Labels, Personal judgments
(A)Assessment
• Assimilate S. and O. section.
• Use professionally acquired knowledge to interpret the information given
by the client during the session.
• Implement clinical knowledge and understanding

Content to avoid:
• Repeating your previous statements in the S. O. sections. In this section,
you should instead include the patient progress.
(P) Planning
• Outline the next course of action as far as the treatment plan goes,
given the preceding information gathered during your session.
• Focus on your next steps for the upcoming session. Stay aligned with
your overall treatment plan without reinstating it in full in this
section.
• Focus on things both parties have agreed to

• Avoid unrealistic, immeasurable goals to be accomplished before the


client’s next session.
Tips for completing SOAP notes:

• Consider how the patient is represented: avoid using words like


“good” or “bad” or any other words that suggest moral judgments
• Avoid using tentative language such as “may” or “seems”
• Avoid using absolutes such as “always” and “never”
Exercise
Make a SOAP note of a patient with hypertension and diabetes:
• Woman, 64 years old, occasional smoker at a young age (4–5 smoked
cigarettes per week for 10 years), overweight since menopause (at
the age of 51) and her blood pressure began to increase. Seven years
ago , she was discovered to be affected by type 2 diabetes, initially
controlled with diet only and then treated with metformin and
glibenclamide. Initially, her hypertension was treated with enalapril
20 mg, but lately her GP added hydrochlorothiazide 25 mg 1 tablet
taken at 12 noon, because of suboptimal BP control. The patient is
really worried for her health, fearing about the possible long-term
effects of high blood pressure and type 2 diabetes on her survival.
Blood Pressure Profile
• Home BP (average): 135/74 mmHg
• Sitting BP: 138/80 mmHg (right arm); 136/78 mmHg (left arm)
• Standing BP: 136/76 mmHg at 1 min
• 24 h BP: 134/74 mmHg; HR: 70 bpm
• Daytime BP: 133/75 mmHg; HR, 75 bpm • Night-time BP: 137/70
mmHg; HR, 54 bpm

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