Soap Notes for Medicl Assistant

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SOAP NOTES
The acronym SOAP defines four sections: (S) for subjective, (O) for objective, (A) for assessment, and (P) for plan. The SOAP note format is common to the medical setting and is used by many health care professionals. Subjective (S). The subjective section should include information given or statements made by the patient or the patient family in relation to the current deficits or ability to participate in evaluation or treatment sessions. For example, a patient who exhibits significant visual difficulty may state, I'm fine to drive a car. This statement may be helpful to include because it provides an example of the patient level of limited insight into how her deficits may affect her performance. The subjective section is optional. If no significant remarks are made that day in the therapy session, then Objective (O): Information included in the objective section pertains to exam results, performance on therapy task, and observations made by the clinician. Assessment (A): This section of the SOAP note contains the problem list and the clinician summary of the session, including the patient performance and short-term and long-term goals. The clinician generally makes comments on progress in this section. If there are other variable that influence the session, those may be noted in this section as well, such as a suggestion that the patient appears to be a good rehab candidate. Plan (P): this section contains recommendations and treatment approaches. Recommendations are made to the physician regarding diet changes, trach tube changes, referrals to other services, and need for follow-up therapy. Treatment plan information may include type of therapy, frequency of therapy, need for further assessment, and plans for discharge. If there are no changes with the treatment plan, the phrase, Will cont. to follow, Can be used. Two examples of a daily progress note written in the SOAP format are shown in figure I-8 and I-9.

1. Most of the clinical work we do in medicine is
Problem focused.
2. About 20 y ago Dr. Lawrence Weed developed
a system of “problem oriented medical record”
Charting.
3. The SOAP note is the fundamental element of
the problem oriented medical record.
4. SOAP notes provide better communication
among multiple providers or over multiple visits
in patient care
5. Proficiency at SOAP note charting is tested in
the USMLE CS test

SOAP NOTES
1. “S” Subjective: important and relevant positives and negatives from a focused hx’

2. “O” Objective: important and relevant positive and negative physical findings, test results.

3. “A” Assessment: list of the differential diagnoses in priority of most likely or important as Determined from S and O.

4. “P” Plan: list of tests or further diagnostic work up intended to narrow, confirm or evaluate dif dx. Should include only tests or work up warranted by S and O, and should be cost Effective.

SOAP
acronym for subjective data, objective data, assessment, plan, the way the progress notes are organized in problem-oriented medical record keeping. SOAP
Patient records a standard format for physician charting of Pt exams on a problem-based Pt record; SOAP combines patient complaints and physician determinations. See Hospital chart, Medical record. SOAP

Subjective data–supplied by the Pt or family
Objective data–physical examination and laboratory data
Assessment–a summary of significant–if any new data, physician conclusions Plan–intended diagnostic or therapeutic action

How do I Write Nursing Soap Notes?
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Jennifer Moyer
Jennifer Moyer, BSN, RN, CBC, has been writing professionally since 1994. Her monthly health advice columns appear in "Ithaca Child," "Ithaca Teen & Parent" and "Tompkins Weekly." She has contributed to peer-reviewed nursing journals and presentations, and is a certified breast-feeding counselor. Moyer holds a Bachelor of Arts in government from Franklin & Marshall College...
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