SOAP Notes

Original Editor - The Open Physio project. Top Contributors -

Rachael Lowe  

Contents

Introduction

SOAP notes are a highly structured format for documenting the progress of a patient during treatment and is only one of many possible formats that could be used by a health professional. They are entered in the patients medical record by healthcare professionals to communicate information to other providers of care, to provide evidence of patient contact and to inform the Clinical Reasoning process.

SOAP is an acronym for:

  • Subjective - What the patient says about the problem / intervention.
  • Objective - The therapists objective observations and treatment interventions (e.g. ROM, Outcome Measures)
  • Assessment - The therapists analysis of the various components of the assessment.
  • Plan - How the treatment will be developed to the reach the goals or objectives.

History

SOAP notes were developed by Dr. Lawrence Weed in the 1960's at the University of Vermont as part of the Problem-orientated medical record (POMR). Each SOAP note would be associated with one of the problems identified by the primary physician, and so formed only one part of the documentation process. However, various disciplines began using only the "SOAP" aspect of the format, the "POMR" was not as widely adopted and the two are no longer related (Quinn & Gordon, 2003).

Advantages and disadvantages

Quinn and Gordon (2003) suggest that the major advantage of the SOAP documentation format is it's widespread adoption, leading to general familiarity with the concept within the field of healthcare. It also emphasises clear and well-organised documentation of findings with a natural progression from collection of relevant information to the assessment to the plan on how to proceed.

However, the format has also been accused of encouraging documentation that is too concise, overuse of abbreviations and acronyms and that it is sometimes difficult for non-professionals to decipher. Delitto and Snyder-Mackler (1995) have also suggested that a sequential, rather than integrative approach to clinical reasoning is encouraged, as there is tendency by the health professional to merely collect information and not assess it. They feel that the emphasis on the problem-orientated approach to documentation is misplaced and that it is not conducive to clinical decision-making.

One major difficulty with SOAP notes for physiotherapists, is the lack of guidance on how to address functional outcomes or goals. Having said that, the format is not so rigid that it cannot be adapted to take this into account.

Writing a SOAP note

While documentation is a fundamental component of patient care, it is often a neglected one, with therapists reverting to non-specific, overly brief descriptions that are vague to the point of being meaningless. There is no policy that dictates the length and detail of each entry, only that it is dependent on the nature of each specific encounter and that it should contain all the relevant information. However, the American Physical Therapy Association does provide the following guidance on what information should be included (Quinn & Gordon, 2003):

  • Self-report of the patient
  • Details of the specific intervention provided
  • Equipment used
  • Changes in patient status
  • Complications or adverse reactions
  • Factors that change the intervention
  • Progression towards stated goals
  • Communication with other providers of care, the patient and their family

Bear in mind that your report will be read at some point by another health professional, either during the current intervention, or in several years time. Therefore, it is your professional responsibility to make sure that it is well-written.

Components of a SOAP note

Subjective

This component is in a detailed, narrative format and describes the patients self-report of their current status in terms of their function, disability, symptoms and history. It may also include information from the family or caregivers and if exact phrasing is used, should be enclosed in quotation marks. It allows the therapist to document the patients perception of their condition as it relates to their progress in rehabilitation, functional performance or quality of life.

Common errors:

  • Passing judgement on a patient e.g. "Patient is over-reacting again".
  • Documenting irrelevant information e.g. patient complaining about previous therapist.

Objective

This section outlines the objective results of the re-assessment, the progress towards functional goals and the treatments performed. It should include details of the interventions, including frequency, duration and equipment used. The therapist should indicate changes in the patient's status, as well as communication with colleagues, family or carers.

Common errors:

  • Scant detail is provided.
  • Global summary of an intervention e.g. "ROM exercises given".

Assessment

This is potentially the most important legal note because this is the therapists professional opinion in light of the subjective and objective findings. It should explain the reasoning behind the decisions taken and clarify and support the analytical thinking behind the problem-solving process. Progress towards the stated goals are indicated, as well as any factors affecting it that may require modification of the frequency, duration or intervention itself. Adverse, as well as positive responses should be documented.

Common errors:

  • The assessment is too vague e.g. "Patient is improving".
  • Little insight is provided.

Plan

The final component of the note is used to outline the plan for future sessions. The therapist should report on what the patient's Home exercise programme (HEP) will consist of, as well as the steps to take in order to reach the functional goals. Changes to the intervention strategy are documented in this section.

Common errors:

  • The upcoming plan is not indicated.
  • Vague description of the plan e.g. "Continue treatment".


Example of a SOAP note

Current condition: COPD/pneumonia

Goals 1. Pt. will demonstrate productive cough in seated position, 3/4 trials. 2. Pt. will ambulate 150ft with supervision, no assistive device, on level indoor surfaces.

S: Pt. reports not feeling well today, "I'm very tired".

O: Auscultation findings: scattered rhonchi all lung fields. Chest PT was performed in sitting (ant. and post.). Techniques included percussion, vibration, and shaking. Pt. performed a weak combined abdominal and upper costal cough that was nonbronchospastic, congested, and non-productive. The cough/huff was performed with VC. Pectoral stretch/thoracic cage mobilizations performed in seated position. Pt. given towel roll placed in back of seat to open up ant. chest wall. Strengthening exercises in standing - pt. performed hip flexion, extension, and abduction; knee flexion 10 reps x 1 set B. Pt. performs HEP with supervision (in evenings with wife). Pt. instructed to hold tissue over trach when speaking to prevent infection and explained importance of drinking enough water.

A: Pt. continues to present with congestion and limitations in coughing productivity. Pt. has been compliant with evening exercise program, which has results in increased tol to therapeutic exercise regime and an increase in LE strength. Amb. not attempted to 20 to pt. report of fatigue. Pt. should be able to tolerate short distance ambulation within the next few days.

P: Cont. current exercise plan including CPT; emphasize productive coughing techniques; increase strengthening exer reps to 15; attempt amb. again tomorrow.

Note: the above example was taken from Functional outcomes - Documentation for rehabilitation, page 125.

Recent Related Research (from Pubmed)

References

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