SOAP note

The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient's chart, along with other common formats, such as the admission note.[1][2] Documenting patient encounters in the medical record is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and medical billing.[3] Additionally, it serves as a general cognitive framework for physicians to follow as they assess their patients.[1]

The SOAP note originated from the problem-oriented medical record (POMR), developed nearly 50 years ago by Lawrence Weed, MD.[1][4] It was initially developed for physicians to allow them to approach complex patients with multiple problems in a highly organized way.[4] Today, it is widely adopted as a communication tool between inter-disciplinary healthcare providers as a way to document a patient's progress.[1]

SOAP notes are commonly found in electronic medical records (EMR) and are used by providers of various backgrounds.[2] Generally, SOAP notes are used as a template to guide the information that physicians add to a patient's EMR.[2] Prehospital care providers such as emergency medical technicians may use the same format to communicate patient information to emergency department clinicians.[5] Due to its clear objectives, the SOAP note provides physicians a way to standardize the organization of a patient's information to reduce confusion when patients are seen by various members of healthcare professions.[2] Many healthcare providers, ranging from physicians to behavioral healthcare professionals to veterinarians, use the SOAP note format for their patient's initial visit and to monitor progress during follow-up care.[4][6][7]

  1. ^ a b c d Gossman, William; Lew, Valerie; Ghassemzadeh, Sassan (2019), "SOAP Notes", StatPearls, StatPearls Publishing, PMID 29489268, retrieved 2019-08-23
  2. ^ a b c d "Understanding SOAP format for Clinical Rounds". Gap Medics US change. 2015-01-02. Archived from the original on 2020-07-22. Retrieved 2019-08-31.
  3. ^ "Ideas and Examples for Improving Workflow". AAP.org. Retrieved 2019-08-31.
  4. ^ a b c Jacobs, Lee (Summer 2009). "Interview with Lawrence Weed, MD: The father of the problem-oriented medical record looks ahead". The Permanente Journal. 13 (3). Kaiser Permanente: 84–89. doi:10.7812/tpp/09-068. PMC 2911807. PMID 20740095.
  5. ^ Short, Matthew; Goldstein, Scott (2019), "EMS, Documentation", StatPearls, StatPearls Publishing, PMID 28846322, retrieved 2019-08-31
  6. ^ "Tips for Writing Better Mental Health SOAP Notes | ICANotes". ICA Notes. 2018-04-25. Retrieved 2019-08-31.
  7. ^ brhargr2. "What is a SOAP? | Wildlife Medical Clinic at Illinois". Retrieved 2019-08-31.{{cite web}}: CS1 maint: numeric names: authors list (link)