Writing SOAP Notes Explained: Your Complete Guide
What is a SOAP Note?
A SOAP note is a type of client progress note or nursing note. It is medical documentation that your team can use to record information about a patient encounter, including the client's diagnosis, condition, treatment and progress.
SOAP notes are named not for the wonderful medical benefits of cleanliness, but for their contents. "SOAP" is an acronym that stands for Subjective, Objective, Assessment, and Plan.
Subjective (S): This section includes the patient's subjective description of their health and symptoms. It may also include elements of the patient's medical history, family history and social history. For example, the SOAP note could detail the history of a patient's illnesses if it could contribute to a more effective and efficient diagnosis of their current condition.
Objective (O): This section includes objective data relevant to a patient's present illness and condition. The information often takes the form of measurable data, and it ranges from a patient's age and vital signs to the results of diagnostic tests. This clinically relevant data is crucial for understanding the patient's status and helps guide the healthcare provider's decision-making process.
Assessment (A): In the assessment section, the healthcare provider reaches a diagnosis based on the subjective and objective information. In some cases, they may opt for a differential diagnosis, which is a list of possible conditions that could explain the patient's symptoms and findings.
Plan (P): The healthcare worker should wrap up the SOAP note with a treatment plan for managing the patient's condition. This could include further tests to resolve diagnostic ambiguities, a specialist referral or patient education. It serves as a guide for future physicians and healthcare providers, as well as an important medical record.
The Many Benefits of Writing SOAP Notes
The SOAP format became popular among healthcare and disability support providers because its structure facilitates clinical reasoning. It prompts the writer to review all the evidence before reaching a logical conclusion and designing a suitable treatment plan.
It also creates a problem-oriented medical record that contributes to a detailed yet reader-friendly medical history. Anyone reviewing the patient’s medical notes would have a strong understanding of the chief complaint and the action that was taken.
By prompting the writer to consider both a patient’s subjective description of their condition and the objective data, it ensures that patients are listened to. And, it allows for data-filled notes that support better decision-making.
Plus, the SOAP format improves communication between caregivers and makes writing a medical record easier. In this way, it helps your team do their job more effectively and efficiently. Simplifying progress notes can lead to time-savings and improved care — and the standardised structure of a SOAP note lends itself well to this.
7 Easy Ways to Support Your Team in Writing SOAP Notes
With the right support, you can streamline the SOAP note process while helping your team improve their quality.
Make sure to:
Provide training: this will help your team adopt the SOAP structure and learn how to quickly write concise, objective statements. For best results, try a mixture of in-person group training, video training and training documentation. Some people learn better in a more interactive environment, while others need time to process the material.
Give feedback: regularly check your team’s SOAP notes, and let them know what they can do to improve. Make sure to praise and thank them when they do it well, too!
Share examples: sometimes, an example can demonstrate what you’re looking for better than a detailed description. These sample notes don’t have to be real to be useful. Consider sharing bad samples, as well, and invite your team to mind-map how they could improve them.
Build templates: by providing your team with a template, you’ll ensure that they don’t forget important information when writing up a SOAP note.
Use mobile apps: you'll see a marked improvement in quality when your team can more easily update client progress notes. For many workers, writing detailed patient documentation via mobile apps is easier compared to using emails or other formats.
Enable voice-to-text technology: some people are slow texters and typewriters. Others struggle with dyslexia or carpal tunnel syndrome. By enabling voice-to-text technology, you can better support your staff and ensure that technology isn’t getting in the way of quality patient documentation.
Foster a supportive environment: you want your team to feel comfortable reaching out to you with their questions and concerns. Emphasise that there’s no such thing as a silly question and that everybody can improve. Respond to queries with a positive attitude. In doing so, you’ll create a culture where people ask for support in creating better participant documentation.
SOAP Notes Made Simple
A well-written SOAP note boosts care quality through facilitating clinical reasoning and improving communication between your team members. And with the right training and support, your team will find that writing a patient's notes is quicker and easier than ever.
ShiftCare's care management software allows you to build progress note templates that will prompt your team to use the SOAP format (or any other format!). You can create specific templates for different client groups to ensure that the most clinically relevant data is included. And with a user-friendly mobile app and voice-to-text technology, creating progress notes couldn’t be more simple.
Plus, ShiftCare comes with a wide range of additional features, from rostering and funds management to accounting integrations and expiry notifications for compliance documentation.
Discover how the right tools can enable your team to consistently produce better progress notes. Try ShiftCare for free.