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What Does
SOAP Mean?
Many medical offices use the
SOAP note format to standardize medical evaluation entries made
in clinical records. The SOAP note is written to improve
communication among all those caring for the patient to display
the assessment, problems and plans in an organized format. SOAP
is an acronym. The letters S-O-A-P stand for SUBJECTIVE,
OBJECTIVE, ASSESSMENT and PLAN. SOAP notes facilitate better
medical care when used in the patient's record for review and
quality control.
SOAP Note Documentation
Medical documentation of patient complaint(s) and treatment
must be consistent, concise and comprehensive, so do it right!
Always
remember: the patient's
medical record is a legal document. The SOAP Note
should briefly express the following:
Date and purpose of the visit
The patient’s symptoms and complaints
The current physical exam: patient's height, weight,
temperature, pulse, blood pressure, visual acuity,
etc.
New lab data and results of studies, reports,
assessments
The current formulation and plan for the patient
SOAP Note Content - Length -
And Purpose
The SOAP note is not supposed to be as detailed as a
progress report. Complete sentences are not necessary and
abbreviations are appropriate. However, avoid them until you
have a handle on how the abbreviations are used—they differ for
each specialty and are consistent within the medical office
where you work.
The length of the note will differ for each specialty as
well. SOAP notes can be flexible. You will develop your own
style as you try to accommodate office preferences. The note
written by a novice will usually turn out to be a little longer
than that of the more advanced staff with more clinical
judgment and experience in proper SOAP note writing format. It
is practice that makes perfect.
The inexperienced writer will often give more thought
as to what to write and usually will wind up putting more of
what they have observed to paper than necessary. A short, but
precise SOAP note is often better than an entry that is too
verbose. As medical assistants experiment and become more
proficient, they eventually develop their preferred technique
to remain short and accurate.
As the medical assistant takes the patient's vital signs, height, and weight measurements it can be entered into the medical record under the "Objective" area
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