A SOAP note is a summary written by a doctor or other health care professional that describes how a patient is doing. The term SOAP is an acronym for the words subjective, objective, assessment, and plan; these four words describe the four sections that make up the note. Typically the note is used to assess the progress a patient has made since the last evaluation. Doctors or other health care professionals write these notes daily on patients in the hospital, and also write them for follow-up outpatient appointments. The SOAP note is an important part of the medical record, and is also important for the purposes of medical billing.
The subjective section of the SOAP note includes information about how a patient is feeling. It can include symptoms the patient is having, as well as how these symptoms have progressed over time. For inpatients, this section can also include how the nurses think the patient is doing, and whether the patient had any major problems in the past day.
Information that can be measured and observed belongs in the objective portion of the SOAP note. This section often starts with a record of the vital signs, including temperature, blood pressure, respiratory rate, and heart rate. The subsequent part of the note includes the findings from the physical examination performed by the doctor or other health care professional. Next, the results of laboratory tests or imaging studies are included.
An evaluation and summary of the patient’s condition is included in the assessment part of the SOAP note. Often, this section includes the different diagnoses a patient has. It addresses how well the patient is doing on his treatment regimen. If the patient doesn’t have any medical diagnoses because information is still being collected, the symptoms that the patient is having are discussed in this section.
Finally, the SOAP note ends with the plan. For hospitalized patients, this generally includes what tests, studies, medications, or other treatments should be done over the next day. Additionally, it can also include longer-term plans regarding when the patient can be discharged. For outpatients, the plan will discuss the treatment regimen that will be followed until the next appointment. The assessment and plan sections of the note are often merged, and a plan is given immediately following the assessment of a certain symptom or diagnosis.
The SOAP note is an important part of the medical record, and is considered to be a legal document summarizing the interaction between the patient and the doctor. The note is also used for medical billing purposes. More complex patients will have a longer note that addresses more topics, and reimbursement will be higher for these cases.
