What are SOAP Notes?

What are SOAP Notes?

Four-step template for consistent charting

The ABC’s of SOAPs

SOAP refers to a standardized method of documenting patient encounters. The purpose of SOAP notes is to provide a roadmap to concisely record patient information efficiently and accurately. The notetaking method also makes it easier to share patient information between clinicians in a way that minimizes confusion and misinterpretation. 

There are four parts to a SOAP note:

Subjective

This is the patient’s complaint—what brings them to a physician’s office. It includes symptoms, when they started, the frequency and severity of the symptoms, the region of the body affected, and other relevant information such as family history, social history, and past and present illnesses.

Objective

This section represents measurable and quantifiable information, including a patient’s vital signs, notes from the doctor’s physical exam, allergies, and reports from diagnostic tests, such as blood tests and imaging.

Assessment

This is the physician’s analysis and includes the diagnoses, patient progress, and evaluation of medication or treatment. It’s generally a summary statement, and should not repeat information in the Subjective and Objective sections.

Plan

This is the treatment plan for the patient’s condition, such as medications, additional procedures and diagnostic tests (if needed), referrals, goals, and follow-up steps. It’s not needed to rewrite a previous treatment plan, but it’s critical to include changes to an existing plan.

The ABC’s of SOAPs

SOAP refers to a standardized method of documenting patient encounters. The purpose of SOAP notes is to provide a roadmap to concisely record patient information efficiently and accurately. The notetaking method also makes it easier to share patient information between clinicians in a way that minimizes confusion and misinterpretation. 

There are four parts to a SOAP note:

Subjective

This is the patient’s complaint—what brings them to a physician’s office. It includes symptoms, when they started, the frequency and severity of the symptoms, the region of the body affected, and other relevant information such as family history, social history, and past and present illnesses.

Objective

This section represents measurable and quantifiable information, including a patient’s vital signs, notes from the doctor’s physical exam, allergies, and reports from diagnostic tests, such as blood tests and imaging.

Assessment

This is the physician’s analysis and includes the diagnoses, patient progress, and evaluation of medication or treatment. It’s generally a summary statement, and should not repeat information in the Subjective and Objective sections.

Plan

This is the treatment plan for the patient’s condition, such as medications, additional procedures and diagnostic tests (if needed), referrals, goals, and follow-up steps. It’s not needed to rewrite a previous treatment plan, but it’s critical to include changes to an existing plan.

3 advantages of SOAP notes

Interoperability and Productivity.
With more healthcare software interoperability on the horizon, SOAP notes make it easier to share patient information across multiple Electronic Health Records (EHR) platforms and providers. Consistent documentation enhances provider-to-provider communication, reduces redundant tests and imaging, and enhances health outcomes.

 

Risk Reduction.
With a prescribed approach to documentation, there is a lower risk of mistakes that can lead to malpractice claims. For example, SOAP notes can help minimize medical record errors that have resulted in
37% of high-severity injury cases in the past. (Interest in learning more about reducing practice risk? Check out RXNT’s Risk Awareness toolkit.)

 

Efficiency.
Healthcare providers have a lot to manage. A standardized template simplifies charting and boosts the time available for patient interactions.

Smart SOAP Form

RXNT’s EHR offers customizable Smart Forms that let you tailor encounters and documentation to your practice. Hundreds of forms are available including a Basic and a Detailed SOAP form with separate “plug-ins” for Vitals, Allergies, Medications, and Orders. Reduce clicks with Short Keys and macros that allow you to quickly add commonly-used text blocks to your encounter templates. 

See our SOAP note template in action

Learning more about SOAP notes or wanting to check out RXNT’s customizable templates? Schedule a quick, no obligation demo with one of our customer advisors.

Used in healthcare organizations of all sizes, from small family clinics to large, multi-specialty practices—we offer flexible pricing options to make our tools accessible to almost any practice. Every product is backed by 24/7 cloud-based access, premium in-house support, and regular system upgrades.

Inc5000_colorstacked
sa_frontrunners_full_color_800x625px_2

Request your demo

Scroll to Top
Copy link
Powered by Social Snap