SOAP stands for subjective, objective assessment and plan.

We sometimes call them SOAP Notes medical, and it’s just a shorthand for one kind of information we should include in the note.

• The subjective is what a patient tells you
• The objective is what you determine yourself through physical exams or labs.
• Imaging assessment is a thought process about what you think is going on, and explaining that entirely in a plan is just that it’s like what you’re going to do next.

This is a SOAP Notes medical format; it’s pretty universal.

So, today, we want to discuss: What are my top three tips for writing a good note?

My Top Three Tips for SOAP Notes medical

Tip Number One for SOAP Notes medical

Write a story.

Keep in mind that when a patient comes to you and has a problem, whatever problem they might have.

They’ll say, “Oh, you know, my hip hurt, and then I was walking, and it hurt more, and now I feel like, you know, maybe it’s getting really, really bad, added.”

 

You ask the patient, “Oh, what-what do you think caused that?.”

Your patient responds, “Oh, you know, I think he may have been because I went to the gym, and I was exercising, so you’re kind of putting together supporting. Sometimes, you know, it’s hard as a patient to kind of put the story in order a chronicle chronological order.”

They’re telling you a bit of this story.

It’s your job in the history and physical, which is also kind of the subjective and objective part, to lay out the story and say, “Okay, look, we understand that you had kind of hip pain, but let’s start with kind of going to the gym and then the hip pain started maybe three days later and then on physical exam or the assessment part I noticed that it’s hard for you to move your hip in a certain direction” so maybe that kind of gives you a clue as to what’s going on.

 

So, that’s telling a good story, you know.

For example, say story, if you’re not telling a good story, it would be like, “Oh, a person had hip pain, and then a month ago they had a runny nose, and it lasted three days, and then they recently travelled to New Zealand.”

“They came back, and they eat a lot of kind of fatty foods”.

It’s kind of all over the place, right?

That’s not a good story.

If you’re listening to a story like, well, what’s going on? Where’s the story arc? What’s even happening?

If you’re watching a TV show like that, you probably click away right to tell a good story.

Write a good story, and make it make sense logically because what it does is it feeds into the following parts of history.

Tell me more about the gym.

What are you exercising where you were exercising the orange lights to write out when you’re making your history in fiscal and writing down your SOAP Notes medical in your subjective and objective?

You want it to flow very naturally, make sense, and build up to a crescendo, which is your assessment.

Tip Number Two for SOAP Notes medical

Remember that when you’re doing the assessment, a diagnosis is a label.

It’s essential that once you write down a diagnosis in your chart, you know you write it in your assessment.

You know, I think this patient has, you know, let’s say, depression or chronic fatigue that label is going to stick with that person they’re going.

Go around that patient chart. It’s going to follow them.

Remember that that’s a challenging label.

Shake off, and I’ll give you a quick story.

I had a patient who was vitamin b12 deficient.

In the chart, it said things like “patients depressed, patients feeling headaches”.

Because it said those things, every time the patient said, oh, I’m fatigued retired, people just said, oh well, you know in the chart it says diagnosis depression so that’s probably what it is and they didn’t think or given any kind of value.

When you write your assessment to write your diagnosis, you know every other doctor is going to see that, and they’re going to think in the same way.

You’re cheating that patient out of giving them a fair shot at getting an accurate diagnosis, so when you write your assessment, think about all sorts of things, like what’s the worst-case scenario?

What is the full differential of what could be going on?

If you’re not sure about something, you can add that in your assessment and say look, this seems possible to be depression.

Other things that we should consider would be, you know, causes like hypothyroidism or vitamin B12 deficiency.

So, write that out, and even if you don’t have the answer, just say there could be other causes or something about this doesn’t make sense.

It’s really important, so just make sure you put your full assessment in there so you don’t cheat someone out of getting the right diagnosis, maybe down the road.

Tip 3 for SOAP Notes medical

Make a specific plan, not just a plan to lose weight, but maybe reduce soda from three times a week to one time a week, start drinking a healthy smoothie for breakfast, and maybe even look up a recipe from the patient.

When you’re doing the plan, I want you to be very specific, so say things like, hey, this patient has agreed to go down on their cigarettes from 20 cigarettes to 10 cigarettes a week, you know, very specific.

That’s why when I started writing SOAP Notes medical, I used to think, oh, you know what, a SOAP Notes medical is a way to communicate with other doctors, nurses and pharmacists.

That’s what I thought, and that’s true, but about a year later, I started meeting with people in the hospital who said, “Hey, we want you to write your SOAP Notes medical.

So that it makes sense for insurance companies for the EMR, we wanted to check all these boxes.

Okay, so the SOAP Notes medical is a legal business document, so we must communicate with insurance companies.

What we’re doing so we get paid so that okay, that’s what a SOAP Notes medical is for, and then as I went on, I realised it’s not just that it is that, but it’s also something more; it’s also a contract between you and your patient.

It’s a trust you’re saying to them, and this is what I know about my SOAP Notes medical.

I read my SOAP Notes medical back to my patient.

You know, at the end, I’ll say something kind of like just quickly highlighting the things that I think are important.

When I start a new visit like a faecium in a few months, I reread it and say hey, last time what we talked about was this, and this is what you’re understanding, and they

say yeah, that’s about right, and they can fill in the gaps, too.

I really want you to think about your progress notes as a contract between you and your patient.

The goal of a good SOAP Notes medical is to get the information right.

Again, writing a good story, tip number one is number two: Make sure the assessment is honestly thought through because the assessment or diagnosis is a label.

Make sure you think about that.

Number three, make sure that when you’re writing a plan.

It’s peculiar.

So again, number one, write a story.

Number two.

Remember that your diagnosis is a label.

Number three, make sure that you write a particular plan.