Medical Assistant .net

Dedicated to all Medical Assistants!

 


medical assistants    Top Medical Assistant Schools! 
       Be instantly matched with schools and programs in your area!
               See schools now!Powered by Edu-Search Net

Writing the SOAP Note

 

   



Who Writes The SOAP Note?

In most cases, SOAP notes are written by the physician and other licensed healthcare providers, such as the physician's assistant (PA), or a licensed nurse practitioner providing hands-on medical care. However, with correct training and proper supervision a medical assistant is also allowed to briefly interview the patient and enter the patient's reason for the visit under the "Subjective" line (S) into the SOAP note.

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 (O) to be reviewed minutes later by the physician.

The medical assistant may also ask about medications taken, and whether the patient has any known allergies to environmental substances, food, or medicines. The patient's response is also listed carefully and accurately under the "O" part of the SOAP note.

Remember: The medical assistant NEVER writes the "Assessment" (A) or the "Plan" (P) in a SOAP note, but should be able to understand this vital part of the medical record entry when reviewing the patient's chart.

 

Free Career Info!

Get this FREE Career Information Kit

As you already know, working medical assistants, as well as recent graduates from vocational training programs should seek certification as soon as possible to succeed!
 

 

SOAP Note Tips:

  1. You should start your entry into the medical record right after the last note in the chart so it will always be in chronological sequence.
  2. It is okay to be bold in your presentations, but conservative when charting.
  3. Since the patient's medical record is a legal document write fluently and legibly and do not leave blank lines in between the text. This is to prevent someone else from writing additional information or comments into your original note. If you made a mistake, simply cross out the unwanted part of the sentence, whether its just one word or several sentences, with a single horizontal line. Then write “error” next to or above the corrected area and initial it.
  4. Never scribble over any part of the note, or use "white-out" to cover a mistake. Those who read and examine a medical record must be able to see mistakes and know who is responsible for crossing a word or sentences out.
  5. For neatness' sake you may want to start at the top of a page and avoid too much (any) blank space above your note. You should also provide room for the doctor, to amend and initial your note at the end.

look Soap Note Examples

 

Last but not least: always sign your notes after your printed name and include your professional title or credentials. Once again, always leave room on the same page for your notes to be amended and cosigned by the physician under whose supervision you are working. This is important for both medico-legal purposes and so others can contact you with questions about what you have written.

 

 
Best Medical Assistant
classes in your state!

Medical Assistant Schools
by Edu-Search Net


Explore Medical Assistant Jobs

 Home Page
 Medical Assistant Web Forum
 What Is a Medical Assistant?
 Administrative Medical Assistant
 Clinical Medical Assistant
 Male Medical Assistants
 Encouraging Male MAs
 Perfect Medical Assistant
 13 Simple Steps
 Medical Assistant Training
 Training Avenues
 Trainee Skill Assessment
 The Externship
 Externship Purpose
 The Externship Site
 Medical Assistant Schools
 Program Accreditation Process
 Program Accreditors
 MA Online Student
 Distance Education And You
 Medical Assistant Instructor
 Studying For Your Finals
 Medical Assistant Certification
 Benefits of Certification
 Certification Required?
 Certifying Agencies
 AMT and NCCA NOCA
 Maintaining Certification (CEU)
 Medical Assistant Work Place
 Front and Back Area
 Working as a Team
 Medical Assistant Outllook
 Med Assist Scope of Practice
 Ultimate Authority in Charge
 Respondeat Superior
 Supervision and Liability
 MAs Can And Cannot Do
 Preventable Incidents
 Can MAs Be Sued?
 Scope of Practice by State
 Medical Assistant Resumes
 Resume Writing Work Sheet
 Sample Cover Letters
 The Chronological Resume
 Medical Assistant Jobs
 Competing For Jobs
 Lack of Experience
 Job Search Tips and Resources
 Medical Assistant Pay
 Wages-Rules-Benefits
 Raises and Promotions
 Medical Assistant Skill Review
 Greek and Latin Word List
 What is a SOAP Note?
 SOAP Note Examples
 Writing a SOAP Note
 Privacy

 Subscribe to News Feed Medical-Assistant-Net---Dedicated-to-All-Medical-Assistants