What does the P in soap stand for medical?

Interconnectivity isn’t as new a concept as some health IT vendors let on. Even though EHRs that easily share patient information between providers are revolutionizing health care, the idea of improving inter-physician communication has been around for decades. A perfect example? SOAP notes.

Today, the SOAP note – an acronym for Subjective, Objective, Assessment, and Plan –  is the most common method of documentation used by providers to input notes into patients’ medical records. They allow providers to record and share information in a universal, systematic and easy-to-read format.

Many elements of modern health care are a byproduct of the SOAP note. EHR systems, a number of HHS’s Meaningful Use objectives, and specialists working off their mobile devices – are all, somehow, built upon the SOAP methodology.

In fact, SOAP notes are so prevalent among physicians that using an EHR equipped with SOAP note template creation is almost unquestionable. The best-designed EHRs combine form and narrative-based functions to create note-taking capabilities that allow you to rapidly drag and drop symptoms as well as input data manually.

Today, we look back at the history of the SOAP note and how it can be applied to modern practices.

The Story Behind SOAP
The SOAP note was first introduced into medicine by Dr. Lawrence Weed in the 1970s, under the name Problem-Oriented Medical Record (POMR).  At the time, there was no standardized process for medical documentation.

SOAP notes gave physicians structure and a way for practices to communicate with each other, a notion that is still transforming the industry. It was the initial users of SOAP notes who were able to retrieve patient records for a given medical problem the fastest – something EHRs do even better today.

Similar to how EHR software has improved the way providers find patient charts, standardized SOAP notes allowed providers to communicate with each other in clear and concise formats. In their own way, both have significantly enhanced the practice of medicine and improved health outcomes for millions of patients.

How To Use SOAP Notes
SOAP notes are broken down into the four components mentioned above, and they’re to be followed sequentially in order to complete a patient’s note.

Initially, the physician fills out the subjective portion, which includes any information received from the patient, such as the history of illnesses, surgical history, current medications, and allergies.

Then, the doctor moves on to the objective component by entering any vital signs and measurements, findings from physical examinations, abnormalities, and results from previous laboratory and diagnostic tests.

Next, the assessment is where the doctor diagnosis the patient’s condition according to the medical history and objective data provided above.

Finally, the plan is where the health care provider will treat the patient’s concerns – such as lab orders, radiological work, referrals, procedures performed, medications given, and education provided. This should address each item of the assessment and speak to what was discussed or advised with the patient, as well as scheduling for further review or follow-ups.

What Does a SOAP Note Look Like?
Below is an example of a SOAP note for a patient who has reported head pain after taking a serious fall.

Fairly straightforward, right? Well, simplicity is what Dr. Weed had in mind when he created this quick and efficient way to document patient encounters, which has segued into the modern medical documentation EHR vendors are working hard to perfect.

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Documenting a patient assessment in the notes is something all medical students need to practice. This guide discusses the SOAP framework (Subjective, Objective, Assessment, Plan), which should help you structure your documentation in a clear and consistent manner. You might also find our other documentation guides helpful.

Subjective

The subjective section of your documentation should include how the patient is currently feeling and how they’ve been since the last review in their own words.

As part of your assessment, you may ask:

• “How are you today?”
• “How have you been since the last time I reviewed you?”
• “Have you currently got any troublesome symptoms?”
• “How is your nausea?”

If the patient mentions multiple symptoms you should explore each of them, having the patient describe them in their own words.

You should document the patient’s responses accurately and use quotation marks if you are directly quoting something the patient has said.

You might also be interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, communication skills and data interpretation.

Objective

The objective section needs to include your objective observations, which are things you can measure, see, hear, feel or smell.

Objective observations

Appearance

Document the patient’s appearance (e.g. “The patient appeared to be very pale and in significant discomfort.”).

Vital signs

Document the patient’s vital signs:

• Blood pressure
• Pulse rate
• Respiratory rate
• SpO2 (also document supplemental oxygen if relevant)
• Temperature (including any recent fevers)

Fluid balance

An assessment of the patient’s fluid intake and output including:

• Oral fluids
• Nasogastric fluids/feed
• Intravenous fluids
• Urine output
• Vomiting
• Drain output/stoma output

Clinical examination findings

Some examples of clinical examination findings may include:

• “Widespread expiratory wheeze on auscultation of the chest.”
• “The abdomen was soft and non-tender.”
• “The pulse was irregular.”
• “There were no cranial nerve deficits noted.”

Investigation results

Some examples of investigation results include:

• Recent lab results (e.g. blood tests/microbiology)
• Imaging results (e.g. chest X-ray/CT abdomen)

Assessment

The assessment section is where you document your thoughts on the salient issues and the diagnosis (or differential diagnosis), which will be based on the information collected in the previous two sections.

Summarise the salient points:

• “Productive cough (green sputum)”
• “Increasing shortness of breath”
• “Tachypnea (respiratory rate 22) and hypoxia (SpO2 87% on air)”
• “Right basal crackles on auscultation”
• “Raised white cell count (15) and CRP (80)”
• “Chest X-ray revealed increased opacity in the right lower zone, consistent with consolidation”

Document your impression of the diagnosis (or differential diagnosis):

• “Impression: community-acquired pneumonia”

If the diagnosis is already known and the findings of your assessment remain in keeping with that diagnosis, you can comment on whether the patient is clinically improving or deteriorating:

• “On day 3 of treatment for community-acquired pneumonia”
• “Reduced shortness of breath and improved cough”
• “Oxygen saturations 98% on air, respiratory rate 15”
• “CRP decreasing (20), white cell count decreasing (11)”
• “Impression: resolving community-acquired pneumonia”

Plan

The final section is the plan, which is where you document how you are going to address or further investigate any issues raised during the review.

Items you to include in your plan may include:

• Further investigations (e.g. laboratory tests, imaging)
• Treatments (e.g. medications, intravenous fluids, oxygen, nutrition)
• Referrals to specific specialties
• Review date/time (e.g. “I will review at 4 pm this afternoon.”)
• Frequency of observations and monitoring of fluid balance
• Planned discharge date (if relevant)