How to write SOAP Notes
Subsequently, How to Write a Soap Note That Gets Noticed
Write SOAP Notes assessment/nursing or medical class common questions (nurses SOAP notes):-
- What is SOAP note format?
- What is a SOAP note and how is it used?
- What does SOAP stand for in therapy notes?
- How do you make SOAP notes?
What is SOAP Notes?
S stands for subjective.
O stands for objective.
A stands for assessment
P stands for plan
The SOAP note is an acronym used by health professionals. Therefore, SOAP note helps portray the presentation and physical exam findings of a patient. When you ask us, “Can you write my SOAP note for asthma” we will do so within the stipulated timeframe. Consequently, The work will also be highly quality and use scholarly sources published in the past five years.
Subjective – “S”
The subjective section encompasses the patient’s personal feelings and complaints. Subsequently, the section discusses the history section of a patient. For example, assume you request for a UTI SOAP note. In this case, the subjective section might include frequency, urgency, and dysuria.
In another scenario, assume a patient presents with complaints of a headache. Therefore, You must elaborate further about the headache in the “S” section of your SOAP note for headaches. You can use the mnemonic SOCRATES to get further information about the headache.
S- site, the specific location, such as frontal region or parietal.
O- onset, when did the pain begin? Was it sudden or gradual?
C- character of the pain. Is it burning, cutting, boring, etc.?
R- Radiation. Does the pain radiate?
A- Associations, such as projectile vomiting or blurring of vision.
T- Timing. Is there a specific time that the pain increases or declines?
E- Exacerbating factors versus relieving factors if any.
S- Severity of the pain. For example, using a score of 1 to 10 where 10 is the most severe form, how would the patient grade the pain’s severity?
Chief Complaint and History of Presenting Illness
From this scenario, it is clear that the first step of a SOAP note assessment is noting the chief complaint (CC). Therefore, the next step of a medical or nursing SOAP note is the history of presenting illness (HPI). HPI elaborates the chief complaint of the patient.
FSHx & PMHx
Once you complete the CC and HPI, you can focus on the family social history and past medical history (PMHx) in your SOAP note example.
Remember to include any familial factors of the patient in the family history. Therefore, if there is a history of asthma, migraine, diabetes, or any other chronic illness, state in this section.
Social history covers the home and environmental factors influencing a patient’s status. The eating, sexual, and employment status of the patient are also part of this section.
PMHx should include the history of any surgeries, blood transfusions, or medical illnesses.
Review of Systems
The next section of the subjective section of the SOAP note is the review of systems (ROS). Therefore, the section should help you use questions focusing on other systems’ complaints.
For example, when you write a SOAP note for the headache, you might also find that the client has abdominal pain. Therefore, Such an approach enables nurses to offer wholesome care.
Current Medications
Once done, you can then include the current medications. However, Details about the drug name, administration route, and frequency should also remain included.
Objective – “O”
This section covers the physical exam findings in your soap note cheat sheet. Subsequently, The exam includes general exams, such as jaundice, pallor, edema, and vital signs. However, Vital signs include blood pressure, respiratory rate, pulse, and temperature.
You also need to include the investigation results in your soap note assessment. Such results include laboratory and imaging results.
For example, assume you are working on a nurses SOAP notes for PUD (peptic ulcer disease). In this case, it is crucial to differentiate what to include in this section and the subjective part. For example, abdominal/epigastric pain will be in the subjective section. But, epigastric tenderness will be in the “O” section of your SOAP notes.
“A” – Assessment (SOAP Notes)
In this section, you will synthesis the previous 2 parts of the SOAP notes. One uses the subjective and objective elements to develop a diagnosis.
Problem
In this section, one identifies the primary diagnosis based on the history and exam. An excellent example would be migraine headache. S
Differential diagnosis (DDx)
The section offers the author an opportunity to outline other possible diagnoses. Aim to always include at least 2 to 3 differential diagnoses of a patient based on new symptoms or signs. For example, DDx for the patient above would include hypertension and head trauma.
“P” – Plan (SOAP Notes)
In this section, include your plan of management of the patient. Such may include more tests required or consultations. Therefore, The section helps nurses and physicians to understand the next step of management.
Start with the list of problems based on the presentation.
State all tests required and indications for each. For example, if suspecting head trauma, order for head CT scan. That would be vital in nursing soap note for headache.
Outline the management strategy for each problem. In hypertension, state the drug, dosage, frequency, and route.
Consultations required.
Patient education. For example, in asthmatic patients, tell them to avoid allergens. Such is important for nurses’ soap notes for asthma.
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SOAP Note examples
Assume an asthmatic patient is attending the first high-risk clinic. In this case, you tell us to “write a soap note for me”.
You can use this soap note sample or template for your work. Subsequently, It can also serve as an ob-gyn soap note example.
Subjective (Soap notes)
M.N. is a 32-year-old Para 1 + 0 G2 female known asthmatic patient presenting for the first HRC session. Her chief complaint is a headache and difficulty breathing on and off. M.N. is currently at 22 weeks gestation.
The client reports that the headache started 2 days ago and is global in nature. The onset was sudden and throbbing in nature. The headache remains associated with shortness of breath and epigastric pain.
The client also reports a history of lower limb swelling for the past week. Besides, in a score of 1 to 10, the patient reports a severity score of 6 but resolves on taking over-the-counter paracetamol.
Past history
The patient reports +ve history of PET in a previous pregnancy, but it resolved during postpartum. But, she is yet to experience an asthmatic attack for the past 2 years. No history of surgery or blood transfusion. Family and social history are unremarkable.
ANC Profile
Unavailable
Obs hx
She delivered via SVD, LMI, 3.5 Kgs, term, alive and well, and had no complications.
ROS
Musculoskeletal – Hip pain.
SOAP Note Example in Mental Health
Here is an example of a SOAP note for a patient with depression:
Subjective
The patient reports feeling sad and hopeless for the past several weeks. Also, She reports a loss of interest in activities she previously enjoyed and difficulty sleeping. She denies any suicidal thoughts or intent.
Objective
The patient’s vital signs are within normal limits. On examination, the patient appears disheveled and unkempt. She demonstrates slowed movements and speaks in a monotone voice. She has poor eye contact and minimal facial expressions.
Assessment
The patient is diagnosed with major depressive disorder. Differential diagnoses include dysthymia. The healthcare provider orders a full blood count and thyroid function tests to rule out any underlying medical conditions contributing to the patient’s symptoms.
Plan
The healthcare provider prescribes an antidepressant medication and recommends weekly psychotherapy sessions. The patient is scheduled for a two-week follow-up appointment to monitor her progress and adjust the treatment plan as needed.
Tips for Writing SOAP Notes
Therefore, When writing SOAP notes, it is important to keep in mind the following tips:
- Use clear and concise language.
- Avoid medical jargon or technical terms that the patient may not understand.
- Use specific and measurable terms to describe the patient’s symptoms and progress.
- Include relevant information only.
- Use correct grammar, spelling, and punctuation.
- Sign and date