The SOAP pattern

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Description: The SOAP pattern is inspired by the traditional SOAP note (an acronym for subjective, objective, assessment, and plan). This is a method of documentation employed by health care providers to write out notes in a patient's chart

Publet Introduction:

Documenting patient encounters in the medical record is an integral part of practice workflow starting with patient appointment scheduling, to writing out notes, to medical billing. Prehospital care providers such as EMTs may use the same format to communicate patient information toemergency department clinicians. Podiatrists, Chiropractors, Physical Therapists, Massage Therapists, among other providers use this format for the patient's initial visit and to monitor progress during follow-up care.

The SOAP pattern is inspired by the traditional SOAP note (an acronym for subjective, objective, assessment, and plan). This is a method of documentation employed by health care providers to write out notes in a patient's chart, along with other common formats, such as the admission note. 

Acknowledgement: Wikipedia 2014, http://en.wikipedia.org/wiki/SOAP_note 

Subjective component  

Initially is the patient's Chief Complaint, or CC. This is a very brief statement of the patient (quoted) as to the purpose of the office visit or hospitalization.

If this is the first time a physician is seeing a patient, the physician will take a History of Present Illness, or HPI. This describes the patient's current condition in narrative form. The history or state of experienced symptoms are recorded in the patient's own words. It will include all pertinent and negative symptoms under review of body systems.Pertinent medical history, surgical history, family history, and social history, along with current medications and allergies, are also recorded. A sample history is one method of obtaining this information from a patient.

The mnemonic below refers to the information a physician should elicit before referring to the patient's "old charts" or "old carts." 

Onset
Location
Duration
CHaracter (sharp, dull, etc.)
Alleviating/Aggravating factors
Radiation
Temporal pattern (every morning, all day, etc.)
Symptoms associated

Objective component

The objective component includes:

  • Vital signs and measurements, such as weight
  • Findings from physical examination including basic systems of cardiac and respiratory, the affected systems, possible involvement of other systems, pertinent normal findings and abnormalities.
  • Results from laboratory and other diagnostic tests already completed.

Assessment 

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 differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. It is the patient's progress since the last visit, and overall progress towards the patient's goal from the physician's perspective.  

Plan

This 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. This should address each item of the differential diagnosis. A note of what was discussed or advised with the patient as well as timings for further review or follow-up are generally included.

Source: Wikipedia article on Soap note


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Target users
Overview
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