SOAP method aims at collecting information throughout a patient’s care experience in real time and in a standardized fashion. it enables to structure the diagnosis process and ensures the audit track. When deployed on a secured cloud and on the appropriate app, the patient’s medical file can be shared by all professionals who need to be involved in the care path. They have access both to detailed information and have an overview of the process followed so far. Moreover, it focuses not only on the practitioners’ point of view but also on the patient’s demand and concerns.
Subjective, Objective, Assessment, Plan: S.O.A.P. is a method used by many healthcare practitioners from nurses to physicians, in the liberal practice, in hospitals or even schools. It is a canvas that helps structure the diagnosis process.
What the patient tells you. In the first section, quote what the patient or his/her family expresses, word by word when relevant. In some cases, when the patient is very talkative-traumatized and provided it is legally authorized, one may need to have an audio recording enclosed to the SOAP note. The family story and social history are stated in this section as well.
Example: Patient says “I was doing cardio training at home, smooth jumping squats when I felt a deep pain in my calf muscles on the upper level. I thought it was a cramp so I drunk water, ate a little made some stretching. But after a break I couldn’t even run. No pain when I am still.” The patient also reports that he had begun his cardio training two weeks ago after two years with no sporting activity. He begins his training right after waking up in the morning.
What you see, measure or read. In the second section, write all your observations, whether the physical general appearance of the patient or the results of specialized tests and the vital signs such as temperature or blood pressure are also reported in this section of the SOAP note. The patient’s gender and age information are concealed here as well. If you take relevant pictures you can enclose them.
Example: Patient is a 45 years old man, is 5,7 feet high and weighs 76kg. Blood pressure at 12/8. He presents bruises on the back of both legs at the higher level of the calf and muscular stiffening. No ache under gentle palpation and nothing abnormal at tendon level.
What you think is going on. Taking into account both the subjective and objective information, the professional states his/her analysis of the situation. A physician will state the differential diagnosis and sort the list of possibilities from the most probable to the least probable. In case of an admission note, differential one may want a checklist or decision tree implemented in the SOAP note in order to help decide on the right degree of emergency.
Example: Local trauma with no other visible sign nor complaint by the patient, due to probable unprepared and intense unusual effort. 1-pulled muscles 2-muscles strain or tear.
What you will do about it. In this section of the SOAP note, one states the prescribed action plan: whether complementary tests such as blood analysis, X-ray, MRI, etc., call for advice from another professional expert in a given field, drugs to be taken or other therapies, etc. The follow-up process will also be stated here when relevant.
Example: 20 sessions physiotherapy massage, 3 times per week during the 2 first weeks, no other activity and complete rest for at least two weeks to be confirmed by physiotherapy progress, apply cold compress 3 times a day and lift legs on cushion while in bed. Drink at least 2l water a day. Progress visit to be scheduled in 15 days with regard to medical leave prorogation.
• While documentation is considered as a boring afterthought by many practitioners, SOAP notes gather information on the spot and with no effort as it helps the practitioner to ensure a thorough analysis of the situation.
• Being done on the spot, it avoids re-transcription errors.
• When stored on a proper secured cloud, It is also a means to communicate between all the professionals who need to know about a patient’s situation. Thus it reliefs a great deal of coordination efforts.
• Customization: a SOAP note usually comprises those 4 sections only. However, some sections may be customized with compulsory fields to be filled such as gender, age, disease referential, etc. in order to ensure the quality of the scrutiny, help in the decision process and in some cases to enable future statistical studies on certain illnesses or pandemics.
<H2> What are the loopholes when using and implementing SOAP notes?
• Stay brief, focused and informative: SOAP notes need to be quickly read and information found easily at the right place.
• Do not interpret or deduce anything in the two first sections. Do not justify your decisions in the plan section either. Keep your thoughts and explanations for the assessment section.
• Do not use the SOAP note to show your genius and knowledge: you would be drowning the useful information in an amount of interesting but useless reading. That would make readers lose time and in some cases of emergency, the reader might miss a vital information.
• Do not ask all professionals to be exhaustive. Post-surgery visit SOAP note will be much shorter than a historical & physical SOAP note which will be quite comprehensive. Adjust the amount and nature of information to the situation.
• Medical data are sensitive data. When implementing SOAP notes on a shared cloud and centralized app, make sure you have the right level of security in order to ensure confidentiality. In particular, all data should not be available to all professionals. By instance, pharmacists do not need to know all the family and social history of the patient.
• Finally, do not over-customize, making the SOAP note cumbersome to use and preventing creativity and outside the box thinking that is needed in complex cases.