Documentation Strategies for Patient Progress in SOAP Notes
SOAP Notes
DOCUMENTATION STRATEGIES
FOR PATIENT PROGRESS:
Therapeutic Shoe Fitter.
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view the presentation in “Slide Show” mode. Click on the “Slide Show” tab in
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SOAP NOTES:
An Overview
SOAP Notes
•
Common format for documenting office visits
•
Ensures consistent organization of information
•
Facilitates communication across disciplines
SOAP Note Sections
S
=
Subjective.
O
=
Objective.
A
=
Assessment.
P
=
Plan.
SOAP NOTES:
Subjective
Things the Patient (or Guardian)
Tells
You:
–
Condition/chief complaint
–
Functional status/activity level
–
Cultural and religious beliefs
–
Employment status
–
Living environment
–
General health status
–
Social/health habits
–
Family health history
SOAP NOTES:
Subjective,
continued
Things the Patient (or Guardian)
Tells
You:
–
Medical/surgical history
–
Medications
–
Growth and development
–
Other clinical tests not available in record
–
Response to treatment intervention
–
Goals
–
Or
… anything else relevant and significant to the
patient’s case or present condition
SOAP NOTES:
Subjective: Documentation Strategies
Be organized and concise; organize by
information type.
Use active verbs—Patient “states,”
“describes,” “denies,” “indicates.”
Quote the patient verbatim.
•
To illustrate confusion or memory loss
•
To illustrate denial
•
To describe pain
SOAP NOTES:
Subjective: Example
Things the Patient (or Guardian)
Tells
You:
For example
:
Complains of tingling in feet.
States that blood sugar last week was “over
280.”
States he/she is unemployed. Goal is to obtain a
part-time job.
Denies any other health issues or concerns.
SOAP NOTES:
Objective
Things You
Find
During the Examination:
–
Physical observation
–
Tests and measurements
–
Functional skills
–
Medical history when taken from the medical
record
–
What do you see, smell, feel?
SOAP NOTES:
Objective: Documentation Strategies
Organize and Categorize.
•
Use headings, caps, and underlining
•
Use tables or charts when appropriate
Be specific.
•
State the affected anatomy
•
State information in measurable terms (steps per
minute, degrees of motion, for example)
State explicit descriptors.
SOAP NOTES:
Objective: Example
Things You
Find
During the Examination:
For example
:
Observed a callus on first metatarsal head.
Patient had no sensation on plantar aspect of
left foot.
Patient arrived wearing sandals.
Your Professional Opinion:
Includes Measurable Data Discovered During the
Examination (temperature, range of motion, pulses, etc. )
and Features:
–
Specific problems
–
Possible interventions and implications
–
Urgency of treatment
–
Inconsistencies
–
Prognosis with/without intervention
–
Consultations and/or referrals needed
SOAP NOTES:
Assessment
SOAP NOTES:
Assessment:
Documentation Strategies
Construct a Cohesive Picture.
Define options.
Explain ramifications.
SOAP NOTES:
Assessment: Example
Professional Opinion:
For example
:
Patient’s loss of sensation …. Indicates he is a
good candidate for …
In need of ongoing patient education ….
SOAP NOTES:
PLAN
Treatment / Intervention for the Problem(s):
–
Anticipated goals (long term and short term)
–
Intervention plan—name, type, style, material, or
device
–
Expected outcomes
•
Behavior (what actions will the person exhibit)
•
Conditions (what is needed for the person to perform
the behavior)
•
Degree (a measure by which you will determine
success)
SOAP NOTES:
Plan:
Documentation Strategies
Address each problem or issue separately.
Provide specific and identifiable descriptions
of all interventions (manufacturer, material,
size, modifications).
Include patient education documentation.
Include follow-up schedule and activities.
SOAP NOTES:
Plan: Example
Professional Opinion:
For example
:
Decided to ……..Will follow up …..
Recommended ……Will see him again …..
SOAP NOTES:
Best Practices
Sign and date notes.
Include patient’s full name AND your full name
and title.
Write legibly or type.
For mistakes made when writing notes, draw a
line through the error, write the word “error,”
and initial.
Chart any phone or other personal contact with
patient.
Note any failed or rescheduled appointments.
Knowledge Check:
Test your knowledge of the material with the following questions.
Proceed to the next slides for the correct answers.
Using the SOAP notes format, in which section would
you note that the patient stated he often feels dizzy
and lightheaded?
Subjective.
Objective.
Assessment.
Plan.
Knowledge Check
Using the SOAP notes format, in which section would
you note that the patient stated he often feels dizzy
and lightheaded?
Answer: Subjective.
Knowledge Check
Using the SOAP notes format, in which section would
you note that the patient works as a welder and
frequently eats fast food?
Subjective.
Objective.
Assessment.
Plan.
Knowledge Check
Using the SOAP notes format, in which section would
you note that the patient works as a welder and
frequently eats fast food?
Answer: Subjective.
Knowledge Check
Using the SOAP notes format, in which section would
you note the patient’s medication—information you
obtained from the prescribing physician’s chart?
Subjective.
Objective.
Assessment.
Plan.
Knowledge Check
Using the SOAP notes format, in which section would
you note the patient’s medication—information you
obtained from the prescribing physician’s chart?
Answer: Objective. (Note: If the patient had stated
what medication he was taking, this would be
subjective.)
Knowledge Check
Using the SOAP notes format, in which section would
you note that the patient stated he diagnosed with
Type 2 Diabetes one year ago?
Subjective.
Objective.
Assessment.
Plan.
Knowledge Check
Using the SOAP notes format, in which section would
you note that the patient stated he diagnosed with
Type 2 Diabetes one year ago?
Answer: Subjective.
Knowledge Check
Using the SOAP notes format, in which section would
you note your recommendation for the patient to
attend a diabetic education class at the community
center next week?
Subjective.
Objective.
Assessment.
Plan.
Knowledge Check
Using the SOAP notes format, in which section would
you note your recommendation for the patient to
attend a diabetic education class at the community
center next week?
Answer: Plan.
Knowledge Check
Using the SOAP notes format, in which section would
you note the patient’s height and weight after you
measured?
Subjective.
Objective.
Assessment.
Plan.
Knowledge Check
Using the SOAP notes format, in which section would
you note the patient’s height and weight after you
measured?
Answer: Objective.
Knowledge Check
Using the SOAP notes format, in which section would
you note a follow up to see the patient in six weeks?
Subjective.
Objective.
Assessment.
Plan.
Knowledge Check
Using the SOAP notes format, in which section would
you note a follow up to see the patient in six weeks?
Answer: Plan.
Knowledge Check
Using the SOAP notes format, in which section would
you summarize any problem(s), based on your clinical
judgment?
Subjective.
Objective.
Assessment.
Plan.
Knowledge Check
Using the SOAP notes format, in which section would
you summarize any problem(s), based on your clinical
judgment?
Answer: Assessment.
SOAP NOTES
This workforce product was funded by a grant awarded by the U.S. Department of Labor’s Employment and
Training Administration. The product was created by the grantee and does not necessarily reflect the official
position of the U.S. Department of Labor. The U.S. Department of Labor makes no guarantees, warranties, or
assurances of any kind, express or implied, with respect to such information, including any information on linked
sites and including, but not limited to, accuracy of the information or its completeness, timeliness, usefulness,
adequacy, continued availability, or ownership. Produced 2016.
HOPE Careers Consortium is a partnership of five institutions of higher education that is building exciting new
programs that will provide valuable career education and training in the Orthotics, Prosthetics, and Pedorthics
(O&P) sector. The five institutions are: Baker College—Flint, Michigan; Century College—White Bear Lake,
Minnesota; Oklahoma State University Institute of Technology—Okmulgee, Oklahoma; Spokane Falls Community
College—Spokane, Washington; and St. Petersburg College—St. Petersburg, Florida.
Although the authoring institution of this educational resource has made every effort to ensure that the
information presented is correct, the institution assumes no liability to any party for any loss, damage, or
disruption caused by errors or omissions.
This work by Oklahoma State University Institute of Technology (OSUIT) is licensed under the Creative Commons
Attribution 4.0 International License. To view a copy of this license, click on the following link:
Creative Commons
Licenses 4.0
.
OSU Institute of Technology
Common format for SOAP Notes documentation includes Subjective, Objective, Assessment, and Plan sections. Subjective notes involve patient information and history, while Objective notes detail examination findings. Effective documentation strategies include organization, use of active verbs, and direct patient quotes to support accurate and concise record-keeping.
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Presentation Transcript
SOAP Notes DOCUMENTATION STRATEGIES FOR PATIENT PROGRESS: Therapeutic Shoe Fitter. To take full advantage of the learning opportunities presented in this resource, view the presentation in Slide Show mode. Click on the Slide Show tab in your tool bar, then click on the From the Beginning tab. As an alternative, you may press the F5 key as a shortcut to begin the presentation.
SOAP NOTES: An Overview SOAP Notes Common format for documenting office visits Ensures consistent organization of information Facilitates communication across disciplines SOAP Note Sections S = O = A = P = Subjective. Objective. Assessment. Plan.
SOAP NOTES: Subjective Things the Patient (or Guardian) Tells You: Condition/chief complaint Functional status/activity level Cultural and religious beliefs Employment status Living environment General health status Social/health habits Family health history
SOAP NOTES: Subjective, continued Things the Patient (or Guardian) Tells You: Medical/surgical history Medications Growth and development Other clinical tests not available in record Response to treatment intervention Goals Or anything else relevant and significant to the patient s case or present condition
SOAP NOTES: Subjective: Documentation Strategies Be organized and concise; organize by information type. Use active verbs Patient states, describes, denies, indicates. Quote the patient verbatim. To illustrate confusion or memory loss To illustrate denial To describe pain
SOAP NOTES: Subjective: Example Things the Patient (or Guardian) Tells You: For example: Complains of tingling in feet. States that blood sugar last week was over 280. States he/she is unemployed. Goal is to obtain a part-time job. Denies any other health issues or concerns.
SOAP NOTES: Objective Things You Find During the Examination: Physical observation Tests and measurements Functional skills Medical history when taken from the medical record What do you see, smell, feel?
SOAP NOTES: Objective: Documentation Strategies Organize and Categorize. Use headings, caps, and underlining Use tables or charts when appropriate Be specific. State the affected anatomy State information in measurable terms (steps per minute, degrees of motion, for example) State explicit descriptors.
SOAP NOTES: Objective: Example Things You Find During the Examination: For example: Observed a callus on first metatarsal head. Patient had no sensation on plantar aspect of left foot. Patient arrived wearing sandals.
SOAP NOTES: Assessment Your Professional Opinion: Includes Measurable Data Discovered During the Examination (temperature, range of motion, pulses, etc. ) and Features: Specific problems Possible interventions and implications Urgency of treatment Inconsistencies Prognosis with/without intervention Consultations and/or referrals needed
SOAP NOTES: Assessment: Documentation Strategies Construct a Cohesive Picture. Define options. Explain ramifications.
SOAP NOTES: Assessment: Example Professional Opinion: For example: Patient s loss of sensation . Indicates he is a good candidate for In need of ongoing patient education .
SOAP NOTES: PLAN Treatment / Intervention for the Problem(s): Anticipated goals (long term and short term) Intervention plan name, type, style, material, or device Expected outcomes Behavior (what actions will the person exhibit) Conditions (what is needed for the person to perform the behavior) Degree (a measure by which you will determine success)
SOAP NOTES: Plan: Documentation Strategies Address each problem or issue separately. Provide specific and identifiable descriptions of all interventions (manufacturer, material, size, modifications). Include patient education documentation. Include follow-up schedule and activities.
SOAP NOTES: Plan: Example Professional Opinion: For example: Decided to ..Will follow up .. Recommended Will see him again ..
SOAP NOTES: Best Practices Sign and date notes. Include patient s full name AND your full name and title. Write legibly or type. For mistakes made when writing notes, draw a line through the error, write the word error, and initial. Chart any phone or other personal contact with patient. Note any failed or rescheduled appointments.
Knowledge Check: Test your knowledge of the material with the following questions. Proceed to the next slides for the correct answers. Using the SOAP notes format, in which section would you note that the patient stated he often feels dizzy and lightheaded? Subjective. Objective. Assessment. Plan.
Knowledge Check Using the SOAP notes format, in which section would you note that the patient stated he often feels dizzy and lightheaded? Answer: Subjective.
Knowledge Check Using the SOAP notes format, in which section would you note that the patient works as a welder and frequently eats fast food? Subjective. Objective. Assessment. Plan.
Knowledge Check Using the SOAP notes format, in which section would you note that the patient works as a welder and frequently eats fast food? Answer: Subjective.
Knowledge Check Using the SOAP notes format, in which section would you note the patient s medication information you obtained from the prescribing physician s chart? Subjective. Objective. Assessment. Plan.
Knowledge Check Using the SOAP notes format, in which section would you note the patient s medication information you obtained from the prescribing physician s chart? Answer: Objective. (Note: If the patient had stated what medication he was taking, this would be subjective.)
Knowledge Check Using the SOAP notes format, in which section would you note that the patient stated he diagnosed with Type 2 Diabetes one year ago? Subjective. Objective. Assessment. Plan.
Knowledge Check Using the SOAP notes format, in which section would you note that the patient stated he diagnosed with Type 2 Diabetes one year ago? Answer: Subjective.
Knowledge Check Using the SOAP notes format, in which section would you note your recommendation for the patient to attend a diabetic education class at the community center next week? Subjective. Objective. Assessment. Plan.
Knowledge Check Using the SOAP notes format, in which section would you note your recommendation for the patient to attend a diabetic education class at the community center next week? Answer: Plan.
Knowledge Check Using the SOAP notes format, in which section would you note the patient s height and weight after you measured? Subjective. Objective. Assessment. Plan.
Knowledge Check Using the SOAP notes format, in which section would you note the patient s height and weight after you measured? Answer: Objective.
Knowledge Check Using the SOAP notes format, in which section would you note a follow up to see the patient in six weeks? Subjective. Objective. Assessment. Plan.
Knowledge Check Using the SOAP notes format, in which section would you note a follow up to see the patient in six weeks? Answer: Plan.
Knowledge Check Using the SOAP notes format, in which section would you summarize any problem(s), based on your clinical judgment? Subjective. Objective. Assessment. Plan.
Knowledge Check Using the SOAP notes format, in which section would you summarize any problem(s), based on your clinical judgment? Answer: Assessment.
SOAP NOTES This workforce product was funded by a grant awarded by the U.S. Department of Labor s Employment and Training Administration. The product was created by the grantee and does not necessarily reflect the official position of the U.S. Department of Labor. The U.S. Department of Labor makes no guarantees, warranties, or assurances of any kind, express or implied, with respect to such information, including any information on linked sites and including, but not limited to, accuracy of the information or its completeness, timeliness, usefulness, adequacy, continued availability, or ownership. Produced 2016. HOPE Careers Consortium is a partnership of five institutions of higher education that is building exciting new programs that will provide valuable career education and training in the Orthotics, Prosthetics, and Pedorthics (O&P) sector. The five institutions are: Baker College Flint, Michigan; Century College White Bear Lake, Minnesota; Oklahoma State University Institute of Technology Okmulgee, Oklahoma; Spokane Falls Community College Spokane, Washington; and St. Petersburg College St. Petersburg, Florida. Although the authoring institution of this educational resource has made every effort to ensure that the information presented is correct, the institution assumes no liability to any party for any loss, damage, or disruption caused by errors or omissions. This work by Oklahoma State University Institute of Technology (OSUIT) is licensed under the Creative Commons Attribution 4.0 International License. To view a copy of this license, click on the following link: Creative Commons Licenses 4.0.
