People who work in the human medical field, as well as veterinary science field, find themselves taking SOAP notes quite regularly. What is a SOAP note, and what are SOAP notes used for? Well, it is a way of documenting the interactions with a client, as well as their progress. It can be a tedious and confusing task, yet it is absolutely necessary. That’s because tracking interactions and progress greatly helps in the treatment of a client.
Created over 50 years ago, SOAP stands for Subjective Objective Assessment Plan. A SOAP note can be considered to be a progress note containing specific information in a specific kind of format. This is done to help gather up all the important and essential information from a session that will be useful. It’s vital to keep SOAP notes as part of medical records, especially since it can be how a claim becomes generated. Also, it shows you care about the needs of clients.
SOAP notes can be taken a few ways. The traditional pen-and-paper method has been the most longstanding way of keeping records, although it is becoming increasingly popular to type up and dictate records as well.
What Are SOAP Notes Used For?
Veterinarians, doctors and therapists alike use SOAP notes to track what’s going on with a client from one visit to another. These notes help provide consistency internally while providing relevant information and specific details. They help keep things organized when it comes to a client, be they a human or animal.
Soap Note Structure
What is SOAP note format? Well, it follows the SOAP acronym and goes like this:
Subjective
This is the first portion of an interaction with a client or patient. It is where they, or someone on their behalf, explains what the chief complaint is. There may be a few issues, but only one is the primary complaint. It’s the job of the professional to listen intently and ask for clarification when it’s necessary.
Asking the right questions leads to informative answers.
The word ‘subjective’ is used because the information is coming from the client’s/patient’s perspective in regard to how they feel. This can also include people close to the client/patient.
Objective
This portion should only include tangible information. This means including lab data, imaging results, diagnostic data, findings from a physical exam, and vital signs. Information should be written in a matter-of-fact way, such as “The patient’s heart rate is X.” Vital signs land in the objective portion and are related to symptoms the client/patient shares in the subjective portion.
Assessment
This section of the SOAP notes is where you combine what you know, given the information in the subjective and objective portions. The veterinarian or healthcare professional will identify the main problem, as well as any contributing factors. Additionally, they will analyze any interaction between the issues that exist, along with changes that may be present. They will then diagnose the problem, form an explanation, and discuss it.
Plan
The final section of a SOAP note is the plan. This is where a healthcare professional or veterinarian will develop a plan to follow. This may include more tests, medications, dietary changes, or other helpful modalities.
SOAP Notes Template
If you want to know how to write a SOAP note, it can be helpful to follow a template. We’ll provide you with an example SOAP note a little later on as well, so you can see how information looks within this kind of template.
Here is a typical SOAP notes template:
Patient Name: ______________________________
Your Name: _________________________________
Date: _______________________________________
SOAP Note
- S – Subjective:
ID:
Chief Complaint (CC):
History of Present Illness (HPI):
Current Medications:
Social History/Habits:
- O – Objective:
Vital Signs:
General Observations:
Physical Examinations:
Diagnostic:
- A – Assessment:
Diagnosis:
- P – Plan:
Diagnostic –
Treatment –
Education –
Consultation –
Follow-Up –
Doctor’s Signature – _______________________________
Date – _____________________
Common Mistakes When Writing SOAP Notes
Even if you are going to use a SOAP notes template, you should be aware of some common mistakes people make when writing SOAP notes for medical records. We’re going to frame these in terms of each individual letter of the SOAP acronym.
Mistakes to Avoid When Writing the Subjective Portion
Avoid including statements that cannot be supported by facts. For example, you shouldn’t say that a client was “willing to participate” because it is merely an opinion until you can give facts supporting such an observation. Also, avoid including any irrelevant information, as well as anything that’s not a direct statement from the client, a loved one, or a teacher that can directly be attributed to a client’s mood, motivation, and willingness to be a participant.
Mistakes to Avoid When Writing the Objection Portion
Avoid making general and vague statements that don’t have supporting data backing them up. This is the section where you want to go heavy on quantitative information.
Mistakes to Avoid When Writing the Assessment Portion
Avoid rewriting what you already stated within the Subjective and Objective portions. The Assessment section is where you can take a step back and view a patient’s/client’s progress or regression as time goes on, assessing which factors led to the changes.
SOAP Note Examples
Now that you have a SOAP notes template and know about the common SOAP note mistakes to look out for, it’s time to look at a SOAP notes example.
Let’s say your client is a woman named Jane Jones, who is meeting with you on a Monday morning.
Your SOAP notes would look something like this:
Session Date: 9/28/20
Session Type: Individual
Time of Session: 9:00 AM
Client Name: Jane Jones
Your Name: Dr. Mary Spalding
S: “They aren’t appreciating how hard I work.”
O: Client did not sit down upon entering. Client paced with her hands making fists. Client sat and began to fidget. Client crumpled up a piece of paper.
A: Client is in need of ideas to communicate better with their superior. Client is in need of help with managing stress.
P: Engage in conflict resolution when opportunities arise. Exercise body scanning. Go for walks at lunch daily for a week.
Here’s another SOAP note example that can help make it even easier to understand how SOAP notes are written. Let’s say your patient is a dog named Annie who you are seeing on a Tuesday afternoon.
Session date: 9/29/20
Type of session: Individual
Time of session: 2:00 PM
Client’s name: Annie
Your name: Dr. Allen Goldstone
S: “Annie is always wanting to come back inside after going into the yard for a few minutes.”
O: Patient is sitting on the examination table, with her head on her paws.
A: Patient needs a way to socialize with other dogs.
P: Introduce patient to other dogs in a safe and controlled environment. Set up and coordinate play dates with other dogs.
As you can see, once you get the hang of SOAP notes, it can become easier.
Wrapping Up
Whether you write them out by hand, type them out, or dictate records, SOAP notes are a necessary process when you are a veterinarian or healthcare professional. You can now be a little more confident in putting together informative and effective SOAP notes for all your clients and patients.
