474:, a list of other possible diagnoses usually in order of most likely to least likely. The assessment will also include possible and likely etiologies of the patient's problem. It is the patient's progress since the last visit, and overall progress towards the patient's goal from the physician's perspective. In a pharmacist's SOAP note, the assessment will identify what the drug related/induced problem is likely to be and the reasoning/evidence behind it. This will include etiology and risk factors, assessments of the need for therapy, current therapy, and therapy options. When used in a problem-oriented medical record (POMR), relevant problem numbers or headings are included as subheadings in the assessment.
25:
483:
disease-state monitoring parameters. This should address each item of the differential diagnosis. For patients who have multiple health problems that are addressed in the SOAP note, a plan is developed for each problem and is numbered accordingly based on severity and urgency for therapy. A note of what was discussed or advised with the patient as well as timings for further review or follow-up are generally included.
222:, or HPI, of the CC. This describes the patient's current condition in narrative form, from the time of initial sign/symptom to the present. It begins with the patient's age, sex, and reason for visit, and then the history and state of experienced symptoms are recorded. All information pertaining to subjective information is communicated to the healthcare provider by the patient or his/her representative.
192:
The four components of a SOAP note are
Subjective, Objective, Assessment, and Plan. The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to
407:
Pertinent medical history, surgical history (with year and surgeon if possible), family history, and social history is recorded. Social history can use the HEADSS (home/environment, education/employment/eating, activities, drugs, sexuality, and suicide/depression) acronym, which gives information
183:
clinicians. Due to its clear objectives, the SOAP note provides physicians a way to standardize the organization of a patient's information to reduce confusion when patients are seen by various members of healthcare professions. Many healthcare providers, ranging from physicians to behavioral
482:
The plan is what the health care provider will do to treat the patient's concerns—such as ordering further labs, radiological work up, referrals given, procedures performed, medications given and education provided. The plan will also include goals of therapy and patient-specific drug and
168:, MD. It was initially developed for physicians to allow them to approach complex patients with multiple problems in a highly organized way. Today, it is widely adopted as a communication tool between inter-disciplinary healthcare providers as a way to document a patient's progress.
494:
A very rough example follows for a patient being reviewed following an appendectomy. This example resembles a surgical SOAP note; medical notes tend to be more detailed, especially in the subjective and objective sections.
210:, or CC, is a very brief statement of the patient (quoted) as to the purpose of the office visit or hospitalization. There can be multiple CC's, but identifying the most significant one is vital to make a proper diagnosis.
1042:
175:(EMR) and are used by providers of various backgrounds. Generally, SOAP notes are used as a template to guide the information that physicians add to a patient's EMR. Prehospital care providers such as
447:, including basic systems of cardiac and respiratory, the affected systems, possible involvement of other systems, pertinent normal findings and abnormalities. The following areas should be included:
965:
408:
like smoking/drug/alcohol/caffeine use and level of physical activity. Other information includes current medications (name, dose, route, and how often) and allergies. Another acronym is
578:
Advance diet. Continue to monitor labs. Follow-up with
Cardiology within three days of discharge for stress testing as an out-patient. Prepare for discharge home tomorrow morning.
723:
470:
A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a
1598:
694:
440:
Vital signs are often already included in the chart. However, it is an important component of the SOAP note as well. Vital signs and measurements, such as weight.
1050:
153:
is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and
436:
The objective section of the SOAP includes information that the healthcare provider observes or measures from the patient's current presentation, such as:
399:
Subsequent visits for the same problem briefly summarize the HPI, including pertinent testing and results, referrals, treatments, outcomes and follow-ups.
934:
184:
healthcare professionals to veterinarians, use the SOAP note format for their patient's initial visit and to monitor progress during follow-up care.
1591:
883:
2122:
1584:
225:
The mnemonic below refers to the information a physician should elicit before referring to the patient's "old charts" or "old carts".
753:
1534:
1145:
2044:
702:
2062:
1985:
1376:
837:
89:
61:
1973:
1884:
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1214:
1179:
1125:
1084:
1023:
910:
108:
2188:
2259:
2057:
1442:
1315:
157:. Additionally, it serves as a general cognitive framework for physicians to follow as they assess their patients.
2115:
2006:
1866:
68:
1632:
46:
1421:
1013:
941:
2290:
2254:
1529:
176:
75:
2264:
1241:, resulting in the SOHP acronym. That acronym can be pronounced as 'soap' but reminds us that we will be
1171:
598:
Referrals: follow up with
Cardiology within three days of discharge for stress testing as an out-patient.
1143:
Cameron, Susan; Turtle-Song, Imani (Summer 2002). "Learning to write case notes using the SOAP format".
2310:
2305:
2295:
2233:
2108:
1853:
1426:
1414:
343:
42:
57:
2269:
2249:
2136:
1980:
1968:
1669:
1664:
1524:
172:
1960:
863:
2052:
1835:
1409:
1369:
754:"Interview with Lawrence Weed, MD: The father of the problem-oriented medical record looks ahead"
35:
331:"On a scale of 1 to 10 (10 being the worst pain you've experienced), how would you rate the CC?"
2089:
2024:
1555:
471:
1896:
1745:
1467:
1071:
Ball, Jane; Dains, Joyce E.; Flynn, John A.; Solomon, Barry S.; Stewart, Rosalyn W. (2019) .
1206:
1114:
The internship, practicum, and field placement handbook: a guide for the helping professions
1940:
1879:
1730:
1712:
1659:
1607:
1565:
1472:
1202:
1168:
The counseling practicum and internship manual: a resource for graduate counseling students
444:
180:
8:
2076:
1861:
1806:
1674:
1576:
1457:
1256:
383:
odifying factors (what aggravates/reduces the symptoms—activities, postures, drugs, etc.)
141:) is a method of documentation employed by healthcare providers to write out notes in a
2300:
2034:
2016:
1909:
1843:
1642:
1560:
1362:
1340:
1313:
Weed, Lawrence L. (June 1964). "Medical records, patient care, and medical education".
1282:
Sames, Karen M. (2015) . "SOAP and other methods of documenting ongoing intervention".
1158:
782:
548:
Abd Bowel sounds present, mild RLQ tenderness, less than yesterday. Wounds look clean.
82:
515:
No further Chest Pain or
Shortness of Breath. "Feeling better today." Patient reports
2213:
2084:
1788:
1637:
1404:
1399:
1332:
1301:
1291:
1270:
1260:
1220:
1210:
1185:
1175:
1166:
Hodges, Shannon (2016) . "Clinical writing and documentation in counseling records".
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1930:
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1154:
777:
769:
2208:
2198:
1935:
1796:
1627:
1619:
1611:
1498:
1199:
Clinical case formulations: matching the integrative treatment plan to the client
154:
1112:
Baird, Brian N. (2014) . "Clinical writing, treatment records, and case notes".
991:
2218:
2183:
2148:
1914:
1801:
1773:
1687:
1503:
1488:
1447:
806:
650:
409:
150:
146:
1094:
389:
dditional symptoms (un/related or significant symptoms to the chief complaint)
2284:
2173:
1679:
1462:
1305:
1274:
1224:
1189:
1135:
920:
165:
412:, which is one method of obtaining this history information from a patient.
2100:
1871:
1813:
1735:
1336:
818:
791:
662:
567:
564:
365:
hronology (better or worse since onset, episodic, variable, constant, etc.)
2158:
2001:
1950:
1755:
1287:
1117:
773:
2153:
1904:
1823:
1818:
1768:
1652:
1328:
1043:"Guidelines for SOAP (Post Encounter Notes), Neis Clinical Skills Lab"
2178:
1740:
1385:
1073:
Seidel's guide to physical examination: an interprofessional approach
461:
Results from laboratory and other diagnostic tests already completed.
24:
2203:
2132:
2029:
1550:
1076:
902:
516:
421:
318:"Is there a particular time of day when the CC is better or worse?"
395:
reatment (has the patient seen another provider for this symptom?)
2168:
1647:
1452:
142:
1253:
Writing patient/client notes: ensuring accuracy in documentation
359:
nset (when injury started and mechanism of injury—if applicable)
2193:
2163:
1692:
1493:
339:
179:
may use the same format to communicate patient information to
1945:
838:"Tips for Writing Better Mental Health SOAP Notes | ICANotes"
649:
Gossman, William; Lew, Valerie; Ghassemzadeh, Sassan (2019),
486:
Often the
Assessment and Plan sections are grouped together.
1354:
935:"The AOA Guide: How to Succeed in the Third-Year Clerkships"
2223:
1722:
1606:
563:
Patient is a 37-year-old man on post-operative day 2 for
864:"What is a SOAP? | Wildlife Medical Clinic at Illinois"
604:
Disposition component: discharge to home in the morning
145:'s chart, along with other common formats, such as the
648:
1070:
601:
Patient education component: that is progressing well
899:
Ferri's practical guide: fast facts for patient care
527:
Afebrile, P 84, R 16, BP 130/82. No acute distress.
213:
49:. Unsourced material may be challenged and removed.
1250:
1142:
1245:instead of plugging in a simple diagnostic label.
2282:
1251:Kettenbach, Ginge; Schlomer, Sarah L. (2016) .
695:"Understanding SOAP format for Clinical Rounds"
804:
592:Diagnostic component: continue to monitor labs
275:"Can you describe the CC you're experiencing?"
2116:
1592:
1370:
588:The plan itself includes various components:
2130:
882:: CS1 maint: numeric names: authors list (
724:"Ideas and Examples for Improving Workflow"
2123:
2109:
1599:
1585:
1377:
1363:
420:All other pertinent positive and negative
415:
1284:Documenting occupational therapy practice
805:Short, Matthew; Goldstein, Scott (2019),
781:
164:(POMR), developed nearly 50 years ago by
109:Learn how and when to remove this message
1011:
989:
149:. Documenting patient encounters in the
1535:Wilderness emergency medical technician
1146:Journal of Counseling & Development
465:
305:"Does the CC move or stay in one spot?"
201:
196:
2283:
1196:
1165:
996:A Practical Guide to Clinical Medicine
751:
453:Characterization of discomfort or pain
431:
2104:
1580:
1358:
1281:
1111:
1037:
1035:
1007:
1005:
998:. University of California San Diego.
896:
644:
642:
640:
638:
292:"What makes the CC better and worse?"
262:"How long has the CC been going for?"
1312:
1243:formulating with clinical hypotheses
990:Goldberg, Charlie (16 August 2008).
861:
747:
745:
743:
689:
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636:
634:
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47:adding citations to reliable sources
18:
1986:Upper limb neurological examination
595:Therapeutic component: advance diet
13:
1159:10.1002/j.1556-6678.2002.tb00193.x
1105:
1032:
1002:
992:"History of Present Illness (HPI)"
338:Variants on this mnemonic include
160:The SOAP note originated from the
16:Method of healthcare documentation
14:
2322:
1197:Ingram, Barbara Lichner (2012) .
740:
674:
615:
477:
171:SOAP notes are commonly found in
1443:Automated external defibrillator
1316:Irish Journal of Medical Science
346:, and LOCQSMAT (outlined here):
214:History of Present Illness (HPI)
23:
2007:Ballard Maturational Assessment
1867:Peripheral vascular examination
1237:of report) will substitute for
1075:(9th ed.). St. Louis, MO:
1064:
983:
958:
377:everity (usually a pain rating)
162:problem-oriented medical record
34:needs additional citations for
1633:History of the present illness
1015:Clinical Naturopathic Medicine
970:American College of Cardiology
927:
901:(9th ed.). Philadelphia:
890:
855:
830:
798:
716:
1:
1974:Mini–mental state examination
1885:Ankle–brachial pressure index
1422:Cardiopulmonary resuscitation
1384:
1201:(2nd ed.). Hoboken, NJ:
1012:Hechtman, Leah (2018-08-16).
608:
489:
187:
177:emergency medical technicians
1530:Emergency medical technician
1018:. Elsevier Health Sciences.
966:"History of Present Illness"
701:. 2015-01-02. Archived from
7:
1172:Springer Publishing Company
752:Jacobs, Lee (Summer 2009).
507:Surgery Service, Dr. Jones
497:
10:
2327:
1427:Emergency bleeding control
402:
371:uality (sharp, dull, etc.)
249:"Where is the CC located?"
220:history of present illness
218:The physician will take a
173:electronic medical records
2242:
2144:
2075:
2043:
2015:
1994:
1981:Cranial nerve examination
1959:
1923:
1895:
1852:
1834:
1787:
1754:
1720:
1711:
1618:
1543:
1525:Certified first responder
1517:
1481:
1435:
1392:
813:, StatPearls Publishing,
657:, StatPearls Publishing,
534:Neck no JVD, Lungs clear
1286:(3rd ed.). Boston:
1116:(7th ed.). Boston:
897:Ferri, Fred F. (2014) .
424:can be compiled under a
236:"When did the CC begin?"
2053:Athletic heart syndrome
1350:(subscription required)
1229:In this book, the term
416:Review of Systems (ROS)
2090:Differential diagnosis
2025:Well-woman examination
758:The Permanente Journal
472:differential diagnosis
193:post-surgical status.
1468:Nasopharyngeal airway
1203:John Wiley & Sons
450:Physical presentation
445:physical examinations
2058:Sudden cardiac death
1941:Shoulder examination
1880:Abdominojugular test
1713:Physical examination
1660:Past medical history
1473:Oropharyngeal airway
1290:. pp. 171–197.
807:"EMS, Documentation"
699:Gap Medics US change
466:Assessment component
456:Psychological status
202:Chief Complaint (CC)
197:Subjective component
181:emergency department
43:improve this article
2291:Medical terminology
2077:Assessment and plan
1862:Cardiac examination
1807:Swinging light test
1675:Psychiatric history
1608:Medical examination
1566:Wilderness medicine
1257:F. A. Davis Company
1174:. pp. 89–114.
1120:. pp. 95–112.
570:. Recovering well.
432:Objective component
288:ggravating factors
2035:Breast examination
1910:Rectal examination
1844:Respiratory sounds
1643:Nursing assessment
1561:Good Samaritan law
1329:10.1007/BF02945791
1235:hypotheses section
1079:. pp. 58–73.
774:10.7812/tpp/09-068
555:Ext without edema
2311:Mnemonic acronyms
2306:Athletic training
2296:Medical mnemonics
2278:
2277:
2098:
2097:
2085:Medical diagnosis
2071:
2070:
1946:Elbow examination
1574:
1573:
1405:Airway management
1400:Abdominal thrusts
905:. pp. 1–34.
766:Kaiser Permanente
586:
585:
582:
581:
428:(ROS) interview.
426:review of systems
119:
118:
111:
93:
2318:
2125:
2118:
2111:
2102:
2101:
1931:Knee examination
1779:Respiratory rate
1718:
1717:
1601:
1594:
1587:
1578:
1577:
1379:
1372:
1365:
1356:
1355:
1351:
1348:
1309:
1278:
1255:(5th ed.).
1247:
1193:
1170:(2nd ed.).
1162:
1139:
1099:
1098:
1068:
1062:
1061:
1059:
1058:
1049:. Archived from
1039:
1030:
1029:
1009:
1000:
999:
987:
981:
980:
978:
976:
962:
956:
955:
953:
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946:
940:. Archived from
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314:emporal pattern
125:(an acronym for
114:
107:
103:
100:
94:
92:
51:
27:
19:
2326:
2325:
2321:
2320:
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2281:
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2238:
2209:RPM-30-2-Can Do
2140:
2129:
2099:
2094:
2067:
2039:
2011:
1990:
1955:
1936:Hip examination
1924:Musculoskeletal
1919:
1891:
1848:
1830:
1797:Eye examination
1783:
1750:
1707:
1628:Chief complaint
1620:Medical history
1614:
1605:
1575:
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1513:
1477:
1431:
1388:
1383:
1349:
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1267:
1217:
1182:
1128:
1108:
1106:Further reading
1103:
1102:
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492:
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208:chief complaint
204:
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155:medical billing
115:
104:
98:
95:
52:
50:
40:
28:
17:
12:
11:
5:
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2260:First response
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1854:Cardiovascular
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1804:
1802:Ophthalmoscopy
1793:
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1774:Blood pressure
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1715:
1709:
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1705:
1704:
1703:
1700:
1695:
1690:
1682:
1680:Progress notes
1677:
1672:
1670:Social history
1667:
1665:Family history
1662:
1657:
1656:
1655:
1645:
1640:
1638:Systems review
1635:
1630:
1624:
1622:
1616:
1615:
1612:history taking
1604:
1603:
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1553:
1547:
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1518:Certifications
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1448:Bag valve mask
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1353:
1352:
1323:(6): 271–282.
1310:
1296:
1279:
1265:
1248:
1215:
1194:
1180:
1163:
1153:(3): 286–292.
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478:Plan component
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443:Findings from
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60: –
59:
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54:Find sources:
48:
44:
38:
37:
32:This article
30:
26:
21:
20:
2228:
1961:Neurological
1915:Bowel sounds
1872:Heart sounds
1736:Auscultation
1697:
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1055:. Retrieved
1051:the original
1047:www.kumc.edu
1046:
1014:
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985:
973:. Retrieved
969:
960:
949:. Retrieved
942:the original
929:
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867:. Retrieved
857:
846:. Retrieved
844:. 2018-04-25
841:
832:
822:, retrieved
810:
800:
761:
757:
731:. Retrieved
727:
718:
707:. Retrieved
703:the original
698:
666:, retrieved
654:
651:"SOAP Notes"
587:
568:appendectomy
565:laparoscopic
493:
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41:Please help
36:verification
33:
2214:SAD PERSONS
2002:Apgar score
1951:GALS screen
1836:Respiratory
1764:Temperature
1756:Vital signs
1653:Medications
1556:Golden hour
1288:Pearson PLC
1118:Pearson PLC
284:lleviating/
58:"SOAP note"
2285:Categories
2255:Cardiology
2154:AEIOU-TIPS
1905:Liver span
1769:Heart rate
1746:Percussion
1731:Inspection
1684:Mnemonics
1393:Techniques
1239:assessment
1231:hypothesis
1205:. p.
1095:1002290924
1057:2019-08-23
951:2019-08-31
869:2019-08-31
862:brhargr2.
848:2019-08-31
824:2019-08-31
811:StatPearls
733:2019-08-31
709:2019-08-31
668:2019-08-23
655:StatPearls
609:References
490:An example
188:Components
135:assessment
127:subjective
99:April 2015
69:newspapers
2301:First aid
2265:Pathology
2179:Hs and Ts
2133:mnemonics
1897:Abdominal
1741:Palpation
1648:Allergies
1482:Mnemonics
1436:Equipment
1386:First aid
1306:858914392
1275:934020211
1225:723035074
1190:915153123
1136:836261561
921:861675782
842:ICA Notes
768:: 84–89.
301:adiation
131:objective
123:SOAP note
2234:SOCRATES
2204:RNCHAMPS
2131:Medical
2030:Pap test
1995:Neonatal
1721:General/
1702:COASTMAP
1551:Bleeding
1458:Dressing
1415:Advanced
1345:44816809
1337:14160426
1077:Elsevier
903:Elsevier
878:cite web
819:28846322
792:20740095
663:29489268
541:Cor RRR
517:headache
422:symptoms
344:SOCRATES
327:everity
271:aracter
258:uration
245:ocation
2270:Various
2250:Anatomy
2169:CASMEET
1814:Hearing
1453:Bandage
975:2 April
783:2911807
728:AAP.org
403:History
353:ocation
143:patient
83:scholar
2219:SAMPLE
2194:OPQRST
2189:MARCHE
2164:ASHICE
2045:Sports
1876:Other
1693:OPQRST
1688:SAMPLE
1544:Topics
1504:SAMPLE
1494:OPQRST
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410:SAMPLE
340:OPQRST
137:, and
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2243:Lists
2159:APGAR
2063:RED-S
1824:Rinne
1819:Weber
1789:HEENT
1410:Basic
1341:S2CID
945:(PDF)
938:(PDF)
764:(3).
232:nset
90:JSTOR
76:books
2229:SOAP
2224:SBAR
2199:RICE
2174:FAST
2137:list
1723:IPPA
1698:SOAP
1610:and
1509:SOAP
1499:RICE
1333:PMID
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1292:ISBN
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907:ISBN
884:link
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139:plan
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1325:doi
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