How many patients does a doctor see per day? A dozen? Twenty? Well, that comes down to how successful a doctor’s practice is and the flow to where he or she works. So, how do doctors remember all that data? They don’t need to, which is why we have paperwork and note-taking. A doctor has enough memorizing to do with all the medical information and clinical skills he/she knows. Of course, if a doctor knows the names of their patients, it’s a great sign and patients love it, but remembering everything about a patient is impossible; patient histories can be pages long and very complicated. Notes are also important for consulting other doctors and discussing a case with them. It’s much easier for someone to hand you three pages to read than for them to recall those pages to you. SOAP notes are used by healthcare providers to document patient data, whether on patient charts or admission notes. It’s also important for medical billing.
SOAP stands for “subjective,” “objective,” “assessment,” and “plan.” Let’s get into more details.
“Subjective” is the part of the note that contains a narration of the patient’s condition. This is done in the patient’s own words, describing what brought them to the hospital or why they’ve come to visit you. It also includes their personal assessment of their function, disability, symptoms, and history. The words of those close to the patient may also be included, but are written down within quotation marks. The subjective part of the notes gives the physician a view of how the patient perceives his or her condition, and this, of course, will relate to rehabilitation and quality of life. Be careful not to include any personal judgment on the patient’s personality or any irrelevant information.
Here are a few points included in the subjective portion:
- Onset: when the complaint happened and whether the onset was acute or gradual
- Chronology/Course: is the condition progressive, regressive, intermittent
- Quality: for example, is the pain sharp or a dull ache?
- Location of the pain
- Frequency: if the complaint is a recurring event, such as vomiting
- Severity: this is usually related to pain
- Radiation of pain to other areas
- Factors that worsen or alleviate the symptom or condition
- Additional symptoms the patient may complain of related to this one
- If the patient is receiving any kind of treatment for his or her complaint
“Objective” is next on the report, and it includes objective data such as the results of a physical examination performed by the physician and the results of any investigations done, as well as therapeutic interventions. The details of these interventions should be included as well, such as the equipment used, the duration of the procedure, and any other details that can be added. Basically, the data in this part of the report are objective, mostly numerical, and can be repeated. Errors made while writing down notes here include giving too little detail and summarizing entire procedures very briefly.
These are the types of data included in the objective portion:
- Vital signs: heart rate, respiratory rate, blood pressure, and temperature
- Findings from physical examinations, such as posture, pallor, cyanosis, clubbing, and organomegaly
- Lab results, such as blood picture, electrolytes, kidney function tests, or thyroid profile
- Any measurements taken, such as weight and height
“Assessment” is the third component of the SOAP note. This can be considered the most important part of the note, legally, because it contains the doctor’s assessment of the condition, which is, of course, based on the previous two parts (subjective and objective). The doctor’s diagnosis here should be explained by giving the reasons that led to this assessment of the condition and supporting the process that led to it. Progress towards the goals the doctor is trying to reach with the patient should also be included. Common errors in the assessment portion include not giving enough detail or explanation as to why this assessment was made, and being too vague, such as simply stating that the patient is getting better or worse.
“Plan” is the last part of a SOAP note. This includes the physician’s outline and plan for the future, such as investigations, procedures, and treatment. Alterations done to the plan and interventions used should also be added here. Errors in writing down the plan include being vague, such as writing down “continue treatment” or not writing an upcoming plan altogether.
The process seems long and complicated, but it isn’t actually; it’s very simple and straightforward if you think about it. It’s an organized way to write down everything you need about the patient that will be included on the patient’s chart or file and will help you if you’re going to present the case to a senior doctor or at a conference.
There are a few things to do in order to make note-taking easy and efficient. These will be especially useful to young residents. Write detailed notes that you can get back to. It’ll be difficult for you to remember every little detail about every single patient, so thorough notes will be of great help. Don’t fall into the mistake of writing down insignificant details, such as the patient complaining about their previous doctor. Know that some details are irrelevant to the case and should not take up part of your notes. They’ll just make it more difficult for you to pick out the important stuff.
Another very important tip is to avoid writing down everything as a patient says it and in the same order. A patient might be talking about a condition that started a week ago, then remember they had a similar issue a few days before that. They might also remember they had received treatment for something they mentioned a few minutes ago. In order to avoid scribbling too much and to keep your notes from looking like a mess, learn to take a breath and think before you write. If you apply this, your notes will be very well written in chronological order, without any missed details.
Your notes will most likely be added to a patient’s chart and their permanent record, which will then be reviewed by other physicians at a later date. You need to know which abbreviations are recognized by all medical professionals and which are not. If your notes are just for you, however, you can use any abbreviations you want as long as you don’t forget what they stand for when it’s time to present your case during rounds to a senior doctor.
Don’t take too much time to present your case during rounds. Five minutes should be enough if the case isn’t too complicated. This will be easy if your note-taking was done in a chronological and well-organized manner. You’re also likely to be asked questions about the case. If you don’t know the answer, just say so. It’s better not to know and admit it than to make stuff up.
The SOAP note first came to life in the 1970s when Dr. Lawrence Weed developed it and called it POMR (Problem Oriented Medical Record). The major advantage of SOAP note-taking is how widely it is used and accepted. This makes it sort of an international method of note-taking. It is also clear and straightforward without too much extra information. This is a feature that has been criticized by some, as the method encourages history- and note-taking that are too concise, which may lead to missing important information.
Note-taking is essential in the field of medicine. A patient’s life can depend on how well you took notes that were eventually added to their record and will be seen by another doctor in fifteen years when they complain of something else that may or may not be related. This is why familiarity with the SOAP note is essential for every physician.