Writing the SOAP Note

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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.

 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.

 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.