Subjective, objective, assessment, and plan (SOAP) notes serve as a method of documenting the clinical encounter between the provider (you) and the patient. SOAP notes are used to document the patient’s subjective data (chief complaint, history of present illness [HPI], and review of systems [ROS]), objective data (vital signs and measurements, physical exam findings, and results from diagnostic testing already completed), assessment (medical diagnosis(es) and differentials), and plan (interventions you will do to treat the patient).
For the purpose of this course, all SOAP notes will include a comprehensive patient history. The physical exam will be determined by the purpose of the exam. An episodic SOAP note includes only those portions of the SOAP that are specific to the chief complaint. For instance, if a patient presents with an eye infection, you would include the chief complaint and any pertinent medical history of the complaint. The ROS would include anything that is pertinent to the complaint. The exam will include the head, eyes, ears, nose, and throat (HEENT) and any other pertinent systems. The assessment and plan should be focused on the acute issue. For systems not used on the form, you may use n/a. Please do not copy and paste your ROS and PE from other resources. Do not document systems that were not examined. Episodic visits generally do not require vaccines and assessment tools. Prudent practitioners make a habit of always documenting a full set of vital signs and a respiratory and cardiovascular exam.
If the patient visit is for the purpose of a well-child visit or a PE, you would be expected to document a comprehensive patient history as well as a comprehensive ROS and PE. This would address all systems. Do not use terms such as “normal”. For instance, do not say “Heart-normal”. Document – “Heart is RRR with S1, S2 -murmurs, rubs or gallops”. We want to know that you know what “normal” represents.
Please be sure to include these tips in your Soap notes-
Here are some tips regarding the SOAP notes:
1. The ROS needs to be completely filled out. You cannot say Denies issues or problems. What issues/problems? You need to write out symptoms.
2. The PE under the objective section is what you observe and examine.
3. You need to include a completed growth chart with EACH SOAP note, do not submit blank growth charts.
4. You need 3 dx EACH week, 1 primary and 2 differentials with ICD- 10 codes for all three. Indicate which dx is your primary and which are your differentials. You need to provide a rationale for each of the diagnoses.
5. Your references must be evidenced based and no older than 2012. You must provide an intext citation within the body of your note to show where your reference applies. This needs to go along with the assessment and the plan section.
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