Soap Notes for Medicl Assistant
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
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