#SOAP NOTES HOW TO#

After you’ve administered treatment to a patient, writing a note about it would inform other physicians that you were able to competently help the patient. It would serve as evidence of your ability and skill to adhere to hospital practices and guidelines.Having these notes would prove that there had been regular patient contact throughout the whole treatment period and the stay of the patient in the hospital. It is an official document which is to be added to the records of patients. It would serve as an important part of the treatment you had provided to a patient.Here are the different benefits of writing SOAP notes:

It is very beneficial to write down notes to keep track of and record the progress of treatments of patients. In the next section, we will be discussing the different benefits of writing SOAP notes to record pertinent data about a patient.Īs you’ve seen from the introduction and the history, a lot of people can write a SOAP note template, nurse practitioners, doctors, nurses and other health care providers in charge of treating patients. The history is short and sweet, but the benefits and sustainability is another story. Now, these are very common and are being used and practiced all over the world. The structured and organized feature of SOAP notes made documentation and communication a lot easier and now, more modern methods are still deriving a lot of their aspects from the simple SOAP notes. Early in the 1970s, those who had begun using these notes were able to retrieve patient information and patient records and use them for reference for other similar medical problems. SOAP notes gave doctors, physicians and other health professionals a way to communicate with each other using a structured and organized format. However, because of the organized format of SOAP notes, a lot of other disciplines started to use it over the POMR, and so it gradually gained popularity. With SOAP notes, each note was made and connected with a concern which had been identified by the main physician, so it served as only one element in the whole recording process. During those times, objective documentation did not exist so physicians had the tendency to make decisions about treating patients without scientific basis. It was done at the University of Vermont as an element of the POMR (Problem-Oriented Medical Record). The very first SOAP note template was created and developed by a brilliant doctor named Lawrence Weed way back in the 1960s. SOAP notes have been around for some time now and because of their efficiency and functionality, they are still being used now. First, let’s discuss a short history of SOAP notes and how they came to be. In this article, you will learn everything you need to know about SOAP notes – from the history, benefits, components to tips and steps in writing it yourself. Using these kinds of notes allows the main health care provider to collect information about a patient from different sources, ensuring that the treatment procedures are accurate. Any type of health professionals can use a SOAP note template – nurse practitioners, nurses, counselors, physicians, and of course, doctors. SOAP notes are a type of documentation which, when used, help generate an organized and standard method for documenting any patient data. These also happen to be the different components of SOAP notes, which we will be discussing further in this article. Plan – This refers to the procedures which will be involved in order to successfully treat the patient or reach whatever objectives have been set at the beginning.

Assessment – This refers to the analysis of the health care providers regarding the different components involved in the assessment.

Objective – This, on the other hand, refers to what the health professionals have observed and what their treatments or intervention procedures are.

Subjective – This basically refers to everything the patient has to say about the issue, concern, problem and intervention procedures.

SOAP is actually an acronym and it stands for:

#SOAP NOTES HOW TO#

7 How to Write SOAP Notes or SOAP Note Templates.

Soap notes