Understanding SOAP Formats for Clinical Rounds

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Many hospitals that are conducting clinical rounds in hospitals at some point have the students present a case to which they must discuss at rounds. The above step includes nurses, attending physicians and residents who will listen to your presentation and try to have an idea of what is going on with the patient being discussed. So, what is a SOAP format?

It needs to be noted that there includes a standard format for providing information about a patient’s background which most clinicians use to both present and write some of the notes seen. A SOAP note which is an acronym that stands for Subjective, Objective, Assessment, and Plan is a method often employed in the healthcare industry and by the providers in ensuring that they have noted in a patient’s chart along with other common formats.

Most of the documentation is seen as an integral part practice workflow that begins from the appointment scheduling of the patient to write out notes to medical billing. SOAP note originated from the then Problem Oriented Medical Record (POMR) that was developed by Lawrence Weed. The above method was initially developed for physicians since they were the only health care providers allowed to write in a medical record. Today, the medical and health industry has evolved as it is widely adopted as a way of communication among health workers.

A soap note contains information about the patient that is written and presented in a specific order including critical components. Many of the notes are used in hospitals for detailing some of the medical histories, admission notes and other documents that are in the chart of a patient. It is evident that with the sudden rise in technology, many hospitals are now using electronic medical records that have templates making it easier for one to enter information into a SOAP note format. It has become a necessary requirement for many healthcare clinics to use SOAP notes as it is the most effective way of communicating among nurses, physical and occupational therapists, and doctors. Medical schools these days must involve the use of SOAP notes putting more emphasis on the format that is required by them when they join the professional industry.

The main reason for most of these hospitals having SOAP notes is to have a standard format that is necessary for organizing outpatient information which is key to ensuring the success of a patient’s life. For one to understand the SOAP format, it is vital for them to understand what each section entails and what it talks about.

Subjective: It is the first letter of the acronym which refers to the subjective observations that are usually expressed in a verbal manner by the patient. Most of the information shared is usually about how they feel, basically symptoms. The main reason why it is considered subjective is that there is no way of measuring information relayed by two patients. The subjective section of your SOAP notes should include a mnemonic known as OLD CHARTS.

Onset: That is used in determining from the patient information to how the symptoms started

Location: refers to a part in the body where the pain is present.

Character: it refers to the type of pain that the patient is enduring which can either be dull, aching etc.

Alleviating factors: Used in determining some of the conditions that reduce or eliminate the symptoms and whether anything makes them worse.

Since medical practitioners have already established where the source of pain, does it radiate anywhere else in the body?

Temporal patterns: Shows whether symptoms have a set pattern which keeps on occurring.

determining whether there are other symptoms related to the condition.

Objective: It is the second section of the SOAP note which involves objective observations. It relates to factors one can see, hear, feel and even smell. In these sections, one includes the vital signs that are seen from the patient such as their pulse, temperature, and even respiration.

Assessment: That refers to how one is going to assess some of the issues the patient is currently undergoing. One assesses the condition or diagnosis a patient has.

Plan: it is the last section of the acronym SOAP that shows how one is going to deal with the patient’s problem. It can include ordering additional tests that rule out or show a certain diagnosis. Here, the patient can be subscribed to more treatment or even slotted for surgery.