In fact, SOAP records are a tool used by health workers to record patient medical records and inform other medical personnel, if needed. In particular, there are several sections that must be filled in the SOAP notes, namely the Subjective (S), Objective (O), Assessment (A) and Planning (P) sections. Because later SOAP records will be transferred from one medical professional to another, make sure you use clear and straightforward language when filling it out. By providing accurate information regarding the patient's diagnosis and health condition, you will undoubtedly help the patient to get the best medical treatment!
Step
Part 1 of 5: Filling in the Subjective Part
Step 1. Ask the patient's symptoms
Ask the patient to share their complaints so you can identify the symptoms they are experiencing. Dig up information about the patient's chief complaint and immediately put it at the top of the SOAP record. The patient's chief complaint or Chief Complaint (CC) can help other medical personnel to analyze the outline of the patient's condition summarized in the SOAP record.
- In the Subjective section of the SOAP notes, you need to write down the various symptoms the patient is experiencing and all forms of treatment that the patient has taken.
- Some of the common medical problems experienced by patients are chest pain, decreased appetite, and shortness of breath.
- If you wish, you may also ask the patient's partner or relative for additional information.
Tip:
If the patient complains of several symptoms at once, pay more attention to the symptom that has the most detailed description to identify their chief complaint.
Step 2. Use the acronym OLDCHARTS to get useful information from patients
In the international medical world, OLDCHARTS is a mnemonic system used by medical personnel to remember questions that need to be asked of patients. After asking the core questions summarized in OLDCHARTS, write down the patient's answers so that SOAP records can be better managed. Specifically, OLDCHARTS is an acronym for:
- Onset: When did the patient first feel the chief complaint?
- Location: Where is the patient's chief complaint?
- Duration: How long has the patient felt the chief complaint?
- Characterization: How would the patient describe his chief complaint?
- Alleviating or aggravating factors: Are there factors that improve or exacerbate the patient's chief complaint?
- Radiation: Does the patient's chief complaint appear only at one point or do they occur intermittently?
- Temporal patterns: Do the chief complaints always appear at specific times?
- Severity: On a scale of 1-10 (10 being the worst), what is the patient's chief complaint scale?
Step 3. Include the patient's family history and/or medical history
Ask if there is a medical or surgical history in the patient's family. If so, include the date of the patient's diagnosis and/or the name of the doctor who performed the operative procedure. Then, identify whether or not the patient's family has a similar condition in order to confirm or eliminate the possibility of genetic problems.
Make sure you only include details that are important to the patient. In other words, do not include a detailed family medical history of the patient if the information is irrelevant
Step 4. Include the name and/or type of medication the patient is currently taking
Ask whether or not there are over-the-counter or prescription drugs that are being taken to treat their main complaint. If there is, note the name of the drug, the dose of the drug, how to take the drug, and the frequency of taking the drug. If the patient is taking several medicines, please write them down one by one.
For example, you might write: Ibuprofen 200 mg taken orally every 6 hours for 3 days
Part 2 of 5: Filling in the Objectives
Step 1. Record the patient's vital signs
Check the patient's pulse, respiration, and body temperature, then write the results in a SOAP record. If the result is higher or lower than the normal limit, double-check to make sure the result is really accurate. Remember, the measurement of vital signs must be done with the correct method so that other medical personnel can immediately understand it with just one look.
The Objectives section of the SOAP record refers to the data you measure and collect from patients
Step 2. Write down the various information you get from the results of the physical examination
In particular, examine the area of the patient's complaint so that you can write down the detailed safety results in the SOAP record. Instead of writing down the patient's symptoms, look for objective signs through the physical examination process. In the end, go back to making sure the contents of your SOAP notes are really clear and neat so as not to confuse other medical personnel when reading them.
For example, instead of writing “abdominal pain,” you could write “pain in the lower abdomen when the area is pressed.”
Tip:
It is recommended that you write down your observations on a separate sheet so that the contents of the SOAP record are neat and well managed.
Step 3. List the results of special examinations performed by the patient
Although it really depends on the severity of the complaint, you may need to perform additional tests, such as an X-ray scan or computed tomography (CT scan). If the patient undergoes additional examinations, make sure the results are included in the SOAP record because it has the potential to affect their treatment process later.
Attach the scan results, as well as photos and/or patient examination data from the laboratory so that other medical personnel can also see it
Part 3 of 5: Filling in the Assessment Section
Step 1. Record any changes in the patient's medical condition
If the patient has consulted with you, or if they have seen another medical professional, chances are that SOAP records already exist that record their medical history. Your next task is to identify changes in the patient's medical complaints, then note the negative or positive effects of the patient's previous treatment methods.
For example, if the patient previously received a prescription for antibiotics, note the reduction in swelling experienced by the patient
Step 2. List the patient's medical problems in order of significance
If the patient has several complaints at once, try to list them in order of severity, with the most severe complaint at the top of the list. If it is difficult to identify the most serious problem, try asking the patient the complaint that bothers the patient the most.
Step 3. List all the diagnoses you made
If you manage to find a clear diagnosis, immediately write it down under the patient's problem. If each problem has a different cause, list all the causes for the most likely diagnosis. Then, re-read the information you have listed in the Subjective and Objective sections to estimate the most likely cause.
If you're having trouble identifying the root cause, try making logical speculations based on all the data you've found
Tip:
If possible, determine one diagnosis that covers several problems at once. Also list various medical conditions that may interact with each other.
Step 4. List the reasons behind the determination of each diagnosis, referring to the information summarized in the Subjective and Objective sections
If the patient has several diagnoses at the same time, do not forget to give special notes if any of the diagnoses feel conflicting.
Always provide a description of each diagnosis so that other medical professionals know the reasons behind your decision to choose a particular treatment method
Part 4 of 5: Filling in the Planning Section
Step 1. Include information about all forms of examination that need to be performed by the patient
Re-read the diagnosis you wrote in the Assessment section of the SOAP record and determine whether or not further tests are necessary to confirm the diagnosis. In particular, list all forms of examination that correspond to each diagnosis in order of significance.
- For example, you may need to have a computed tomography procedure or an X-ray examination to determine the underlying cause of the medical problem.
- Include information about the steps that the patient needs to take after carrying out a special examination, both if the results are positive or negative.
Step 2. Write down any therapy or treatment method the patient should try
If you feel that the patient needs rehabilitation, such as through mental or physical therapy, do not forget to include this information. On the other hand, if the patient only needs to take drugs prescribed by the doctor, simply state the type of medication needed along with the dosage and duration of treatment.
Sometimes, surgical procedures need to be performed if the patient's condition is severe enough
Step 3. Include a referral for consultation with a specialist, if necessary
If the type of treatment or treatment needed by the patient is not in accordance with your field of knowledge, please include a referral to a specialist doctor that the patient needs to visit. In particular, recommend the name of the appropriate specialist for each diagnosis, if the specific cause has not been identified, so that the patient knows where to go next.
Part 5 of 5: Setting the SOAP Record Format
Step 1. List the patient's age, gender, and complaints at the beginning of the note
At the very top of the SOAP record, list the patient's age and gender, followed by the medical complaint. This way, other medical professionals only need to look at your records once to identify the patient's medical diagnosis and possible treatment.
For example, you could write, “45 year old woman has lower abdominal pain,” to open a SOAP note
Step 2. Make sure the order of the contents in the SOAP record is correct
This means that all patient information you receive must be recorded in a Subjective-Objective-Assessment-Planned format. Thus, other medical personnel who read the note will not lose their way. If you want, instead of taking notes in sentence form, you can also use bullet points. Whatever format you use, make sure the results are clear, concise, and easy to read.
Basically, there are no rules regarding the format or length of content, as long as the order of content in SOAP records is Subjective-Objective-Assessment-Planning
Tip:
Make sure all medical abbreviations or jargon you use are easy to understand for readers from all walks of life.
Step 3. Write or type SOAP notes in the format your workplace requires
Most clinics have used a digital record-keeping system using online forms to simplify the process of filling and disseminating SOAP records. However, there are still some places that require employees to manually create SOAP records. Make sure you always follow the format required by your workplace to make the results easier to manage.
Tips
In fact, there is no long or short limit on writing SOAP notes. Most importantly, the note should contain all the necessary information and be easy to read
Warning
- Organize all sections in a SOAP record so that it is always neat and easy to read. That way, other people will not be confused when reading the patient's medical record that you create.
- So that others don't get confused when reading your SOAP notes, don't use too many abbreviations or acronyms in them.
