Preparation and discussion of SOAP notes: Pharmacotherapeutics
Introduction:
The Subjective, Objective, Assessment and Plan (SOAP) note is an acronym representing a widely used method of documentation for healthcare providers to write out notes in a patient’s chart, along with other common formats, such as the admission note
The four components of a SOAP note are Subjective, Objective, Assessment, and Plan
This widely adopted structural SOAP note was theorized by Larry Weed almost 50 years ago. It reminds clinicians of specific tasks while providing a framework for evaluating information. It also provides a cognitive framework for clinical reasoning. The SOAP note helps guide healthcare workers to use their clinical reasoning to assess, diagnose, and treat a patient based on the information provided by them. SOAP notes are an essential piece of information about the health status of the patient as well as a communication document between health professionals. The structure of the documentation is a checklist that serves as a cognitive aid and a potential index to retrieve information for learning from the record
Components of a SOAP
Subjective
This is the first heading of the SOAP note. Documentation under this heading comes from the “subjective” experiences, personal views or feelings of a patient or someone close to them. In the inpatient setting, interim information is included here. This section provides context for the Assessment and Plan.
- Chief Complaint (CC)
- History of Present Illness (HPI)
- History
- Review of Systems (ROS)
- Current Medications, Allergies
Objective
This section documents the objective data from the patient encounter. This includes:
- Vital signs
- Physical exam findings
- Laboratory data
- Imaging results
- Other diagnostic data
- Recognition and review of the documentation of other clinicians.
Assessment
This section documents the synthesis of “subjective” and “objective” evidence to arrive at a diagnosis. This is the assessment of the patient’s status through analysis of the problem, possible interaction of the problems, and changes in the status of the problems
Plan
This section details the need for additional testing and consultation with other clinicians to address the patient’s illnesses. It also addresses any additional steps being taken to treat the patient. This section helps future physicians understand what needs to be done next
- State which testing is needed and the rationale for choosing each test to resolve diagnostic ambiguities; ideally what the next step would be if positive or negative
- Therapy needed (medications)
- Specialist referral(s) or consults
- Patient education, counselling
Advantages of SOAP
The major advantage of the SOAP documentation format is its widespread adaptation, which leads to general familiarity with the concept within the field of healthcare. It also provides clear and well-organised documentation of finding with a natural progression from the collection of relevant information to deciding guidelines for a plan on how to proceed with medical treatment.
Disadvantage
Overuse of abbreviations and acronyms may lead to making some times difficulties for non-professionals it requires only a trained person.
The misplaced in the documentation of SOAP notes leads to make problems in clinical decision-making.
Do’s & Don’t SOAP Note
Do’s
Be concise
Be specific
Write in the past tense
Don’t
Make general statements
Use words like “seem” and “appear”
References: https://www.ncbi.nlm.nih.gov/books/NBK482263/
https://blog.capterra.com/free-soap-notes-templates/F Y D Pharm & S Y D Pharm Notes, Books, Syllabus, PDF, Videos
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