Understanding SOAP Notes in Physical Therapy

SOAP notes play a crucial role in documenting patient care in physical therapy. These concise records follow a problem-oriented approach and serve as a communication bridge among healthcare providers. What is a SOAP Note? is a key concept in nursing education that supports accurate and efficient patient care documentation.

Let’s delve deeper into the meaning of SOAP notes and explore how to create effective ones.

 

What Is a SOAP Note in Physical Therapy?

 

• SOAP Acronym:

SOAP stands for Subjective, Objective, Assessment, and Plan.

• Purpose:

A physical therapy SOAP note is entered into a patient’s medical record to document each care episode comprehensively.

• Clinical Reasoning:

It informs the clinical reasoning and facilitates communication with other healthcare professionals.

Key Components:

• Subjective:

Captures the patient’s perspective, including feelings, symptoms, and functional status.

• Objective:

Records measurable data and observations.

• Assessment:

Analyzes information and guides clinical decisions.

• Plan:

Outlines the treatment plan.

The Historical Significance of SOAP Notes

• Origins:

Lawrence Weed developed SOAP notes in the 1960s as part of the problem-oriented medical record (POMR).

• Widespread Adoption:

Physicians quickly embraced SOAP notes as the primary method for documenting and sharing identified problems.

• Relevance in Physical Therapy:

These notes have also gained popularity in physical therapy due to their organised approach to tracking patient progress.

• Legal Obligation:

Physical therapy SOAP notes serve as a roadmap for other treatment providers and fulfil therapists’ legal documentation requirements for insurance purposes.

By understanding “What is a SOAP Note?” nursing students learn to capture essential patient information systematically.

 

Nursing tutorials often include “What is a SOAP Note?” sections to guide students through the documentation process.

Writing Effective SOAP Notes in Physical Therapy

If you’re wondering how to create a SOAP note or are concerned that it might detract from patient care, fear not! The process is straightforward. Let’s explore the four essential sections of a physical therapy SOAP note and their functions:

 

1. Subjective Section: Patient Self-Report

The Subjective section is influenced by the patient’s personal feelings and opinions. It provides a detailed narrative from their perspective, including:

 

• Current Condition:

Describe the patient’s symptoms, complaints, and overall well-being.

• Activity Level:

Note any changes in their functional abilities.

• Quality of Life:

Understand how their condition impacts their daily life.

• Treatment Progress:

Gather insights into how they perceive their response to therapy.

• Overcoming Challenges:

Explore their outlook on overcoming their condition.

Incorporate relevant medical information from the patient’s chart, especially if you didn’t directly observe specific findings. When quoting family members or the patient, use quotation marks for accuracy.

Practising “What is a SOAP Note?” helps nursing students develop clinical reasoning and documentation skills.

 

The Objective Section in SOAP Notes for Physical Therapy

 

The Objective section in a SOAP note is the counterpart to the Subjective section. Here, we focus strictly on observations that are documented in measurable terms. This section provides critical information for analysing patient progression over time. Let’s explore what the Objective section entails:

• Activity Limitations:

Document any patient’s restrictions or challenges in performing daily activities. These observations help gauge functional abilities.

• Participation Restrictions:

Note any limitations that affect the patient’s participation in work, leisure, or social activities. These details provide valuable context.

• Impairments of Body Structure and Function:

Record specific physical impairments, such as limited range of motion, muscle weakness, or sensory deficits.

The Objective section should be specific enough that any healthcare provider—a physical therapy assistant or a primary doctor—can seamlessly continue from where the SOAP note leaves off. These details contribute to quantifying progress toward functional goals and treatment effectiveness.

“What is a SOAP Note?” is a fundamental question that nursing students must confidently answer.

Assessment and Plan in SOAP Notes for Physical Therapy

1. Assessment: Professional Reasoning

The Assessment section in SOAP notes is critical for legal compliance, mainly concerning insurance and Medicare requirements. Here’s what it entails:

 

• Reasoning Behind Treatment:

Explain the rationale behind both diagnosis and treatment.

Key Components:

• Ultimate Goals:

Define the treatment objectives.

• Influence of Findings:

Describe how subjective and objective data influenced treatment decisions.

• Patient-Specific Approach:

Explain why the treatment aligns with the patient’s condition.

• Addressing Factors:

Consider any factors that impact treatment goals and propose solutions.

The Assessment section evolves with each care episode, reflecting the therapist’s professional opinion. Include updates on patient progress toward goals and any responses to treatment.

 

2. Plan: Treatment Goals and Outcomes

The Plan section outlines the patient’s treatment trajectory. Beyond a simple continuation of the existing protocol, it should cover:

 

• Frequency of Care:

Specify how often treatment sessions will occur.

• Interventions:

Detail the specific therapeutic approaches.

• Equipment Requirements:

Note any necessary equipment.

• Treatment Progression:

Describe how the plan evolves.

• Home Exercise Program (HEP):

Include exercises for the patient to perform independently.

• Patient Education:

Provide strategies for informed self-management.

Avoid vague descriptions; clarity ensures effective provider communication and supports patient progress.

Faculty often asks, “What is a SOAP Note?” to ensure students can effectively communicate patient information.

Creating Effective SOAP Notes in Physical Therapy

 

SOAP notes provide a structured method for documenting patient progress. Beyond the basic four sections—Subjective, Objective, Assessment, and Plan—there are additional elements to include. Here’s what you should consider:

 

1. Subjective Section

 

• Patient Self-Report: Include direct quotes from the patient whenever possible.
• Intervention Details: Describe the treatment provided.
• Equipment Usage: Explain how specific equipment was used.
• Complications or Adverse Reactions: Note any unexpected responses.
• Factors Impacting Intervention: Consider external factors affecting treatment.
• Patient-Reported Updates: Capture changes reported by the patient.
• Functional Measurements: Use quantifiable data to demonstrate progress.
• Communication: Document interactions with other providers and the patient’s family.

 

2. Objective Section

 

• Pain Symptoms: Record observations, such as leg raise differences.
• Functional Measurements: Assess range of motion and other relevant metrics.

 

3. Assessment Section

 

• Professional Reasoning: Explain the rationale behind diagnosis and treatment.
• Treatment Goals: Define objectives based on findings.
• Patient Compliance: Acknowledge adherence to at-home exercises.

 

4. Plan Section

• Treatment Trajectory: Describe the plan beyond the current protocol.
• Frequency of Care: Specify session frequency.
• Interventions: Detail specific therapeutic approaches.
• Patient Education: Include strategies for informed self-management.

Clear and comprehensive SOAP notes support effective patient care and compliance.

Nursing students who understand what is a SOAP note are better prepared for clinical documentation tasks.

Understanding SOAP Note Format in Healthcare

SOAP notes are a structured way to document patient encounters. Let’s break down each section:

 

Subjective (S):

• Represents the client’s perception of symptoms, needs, and progress.
• Include verbatim comments from the client.
• Capture relevant details reported by the client.

Objective (O):

• Contains the practitioner’s observations:
• Screening tools
• Historical information
• Medications prescribed
• Vital signs
• Provides a broader view of the client’s physical and mental status.

Assessment (A):

• Summarizes both subjective and objective sections.
• Helps clinicians recall previous sessions.
• Notes progress toward treatment goals.

Plan (P):

• Outlines the agreed course of action:
• Specific, measurable goals
• Further assessments
• Interventions
• Referrals
• Follow-up appointments

 

Understanding SOAP Notes in Healthcare

 

In healthcare and medical documentation, effective communication is paramount. Professionals across disciplines rely on standardised methods to share patient information, ensuring accuracy and comprehensiveness. Among these methods is a tool that has stood the test of time: the SOAP format. Let’s explore its significance and application:

 

What Is a SOAP Note?

 

The SOAP note is a widely used documentation method in healthcare. It stands for:

 

• Subjective: Captures the client’s perception of symptoms, needs, and progress.
• Objective: Provide the practitioner’s observations, including screening tools, historical information, medications, and vital signs.
• Assessment: Summarizes subjective and objective sections, aiding recall of previous sessions.
• Plan: Outlines the agreed-upon course of action, including specific goals and interventions.

To clarify, what is a SOAP note? It is a systematic approach to documenting patient health status and care plans.

Purpose of SOAP Notes

SOAP notes serve several purposes:

 

1. Effective Communication:

• Facilitate communication among healthcare providers.
• Ensure important patient information is shared accurately.

2. Better Patient Care:

• Essential for high-quality care.
• Track medical history, symptoms, and treatment plans.

3. Legal and Regulatory Compliance:

• Used for documentation, billing, and legal proceedings.
• Compliance with requirements is crucial.

4. Career Development:

• Vital skill for healthcare professionals.
• Often required for certification and licensure.

Learning about SOAP notes is essential for effective communication, improved patient care, compliance, and professional growth.

Acronym SOAP Explained – What is a SOAP Note?

The SOAP note is a widely used method of documenting patient information in the medical field, consisting of four sections:

 

• Subjective:

This section captures information the patient reports, including symptoms, concerns, and medical history. It is based on the patient’s subjective experience and often recorded in their own words.

 

• Objective:

This section includes data gathered through observation, examination, and testing. It encompasses vital signs, physical exam findings, laboratory and diagnostic test results, and other measurable or observable information.

 

• Assessment:

This section presents the healthcare provider’s assessment or diagnosis of the patient’s condition, integrating subjective and objective information. It may also include the provider’s impressions or conclusions.

 

• Plan:

This section outlines the healthcare provider’s plan for treatment or management of the patient’s condition based on the assessment. It may detail prescribed medications, recommended procedures, referrals, and follow-up instructions.

 

By recording all relevant information in a SOAP note, healthcare providers ensure that patient data is easily accessible to others involved in care, contributing to seamless healthcare delivery.

Answering what is a SOAP note involves describing its four key components: Subjective, Objective, Assessment, and Plan.

Subjective Section Details

The subjective section is based on the patient’s personal experience and may include the following information:

 

• Chief Complaint:

The main reason the patient seeks medical attention, such as a specific symptom (e.g., chest pain, headache) or a general concern (e.g., feeling unwell).

• Symptoms:

Additional symptoms the patient is experiencing, like coughing, fatigue, or nausea.

• Medical History:

Details about the patient’s past and current medical conditions, including chronic illnesses, allergies, surgeries, or hospitalizations.

• Family History:

Information on the patient’s family’s medical history, including hereditary or genetic conditions.

• Social History:

Relevant lifestyle and social factors, such as smoking, alcohol or drug use, and occupation.

• Review of Systems:

A systematic review of the patient’s body systems (e.g., respiratory, cardiovascular, gastrointestinal, neurological) to identify additional symptoms or concerns.

 

Gathering information in the subjective section is crucial for establishing a baseline of the patient’s health status and determining the appropriate course of treatment. It helps healthcare providers understand the patient’s perspective and concerns, which is essential for building trust and rapport.

What is a SOAP note? Is an integral question to nursing documentation and ensures continuity of patient care.

Objective

This section provides an objective view of the patient’s condition and helps healthcare providers make informed decisions about diagnosis and treatment. Here are some examples of the type of information included in the objective section:

 

• Vital signs:

Measurements of the patient’s vital signs, such as blood pressure, heart rate, respiratory rate, and temperature.

• Physical examination findings:

A detailed examination of the patient’s body systems and physical condition. This includes skin color, the appearance of the eyes, throat, and ears, and palpation of different organs such as the abdomen, lymph nodes, etc.

• Diagnostic tests:

Results from laboratory tests, such as blood tests, urine tests, and imaging studies, such as X-rays, CT scans, or MRIs.

• Medication:

The medication the patient takes or is administered during the visit.

• Patient history:

Any relevant information obtained from the patient or their medical records, including prior medical conditions and procedures.

 

By documenting this objective information, healthcare providers can track changes in patient conditions over time and adjust treatment plans accordingly. Additionally, this information can be used to communicate with other healthcare providers involved in the patient’s care.

Knowing what is a SOAP note enables nursing students to create accurate and comprehensive patient records.

Assessment

This section covers inferences drawn from conducted tests and diagnoses. It may also include impressions or conclusions drawn from the information provided. Here are some examples of the type of information that the healthcare provider may include in the assessment section:

 

• Diagnosis:

The diagnosis of the patient’s condition is based on the subjective and objective information gathered. It may include a list of possible diagnoses if it is unclear or further testing is needed.

• Impressions:

This describes the healthcare provider’s conclusions based on the information provided. Impressions may include the severity of the patient’s condition or the likelihood of certain diagnoses.

• Plan for further testing:

If additional tests are needed to confirm the diagnosis, the healthcare provider may outline a plan for further testing or a referral to a specialist.

• Prognosis

details the healthcare provider’s assessment of the patient’s expected outcome or course of treatment.

 

The SOAP note records the patient’s progress over time by recording the healthcare provider’s assessment of the patient’s condition. This information is then communicated to other healthcare providers involved in the patient’s care, such as consulting physicians or specialists. Consequently, continuity of care is guaranteed.

When preparing for clinicals, nursing students must be able to explain, what is a SOAP note.

Plan

This section shows the plan of action. Here are some examples of the type of information that may be included in the plan section:

 

• Treatment plan:

The healthcare provider’s plan for addressing the patient’s condition. This may include medication, therapy, or other interventions.

• Medications:

A list of medications prescribed, including the dose, frequency, and duration of treatment

• Follow-up care:

The healthcare provider’s plan for follow-up care, which may include additional appointments, laboratory tests, or referrals to specialists

• Patient education:

Any instructions or information provided to the patient to help them manage their condition or improve their health.

• Prognosis:

A description of the expected outcome of the patient’s treatment and the projected course of recovery

By recording this plan, the SOAP note guides all healthcare providers to follow in managing patient care.

“What is a SOAP Note?” is a topic covered extensively in nursing education to prepare students for real-world scenarios.

Benefits of SOAP Notes

 

Accurate and complete SOAP notes are essential in healthcare for several reasons:

 

• Communication: SOAP notes provide a structured and organized method for healthcare providers to communicate about a patient’s care. They are a standardized format for documenting crucial information about a patient’s condition, making it easy to share among healthcare providers.

 

• Continuity of care: SOAP notes ensure continuity of care by offering a clear and concise summary of a patient’s condition and treatment plan. As patients transition through different healthcare settings or see multiple providers, SOAP notes serve as a reference to maintain consistent and appropriate care.

 

• Better patient outcomes: By using a structured format to document a patient’s condition, healthcare providers can make more informed decisions regarding diagnosis and treatment, leading to better patient outcomes and improved quality of care.

 

• Legal protection: SOAP notes can act as legal documentation in the event of a malpractice lawsuit or other legal action. By recording the patient’s condition, treatment plan, and response to treatment, healthcare providers can protect themselves in case of a legal challenge.

Nursing exams often include questions like what is a SOAP note? to test students’ understanding of clinical documentation.

• Quality improvement: SOAP notes can be used to track patient outcomes and identify areas for quality improvement. By analyzing data within SOAP notes, healthcare providers can recognize patterns and trends in patient care and implement changes to enhance the quality and effectiveness of care.

 

Paving the way for Electronic Medical Records

 

SOAP notes have significantly contributed to the development and implementation of electronic medical records (EMRs) by establishing a standardized format for documentation, which facilitates the transition to digital record-keeping systems.

 

• Standardization: SOAP notes offer a standardized format for documenting patient information. EMRs adopt a similar format, facilitating the transition to electronic documentation for healthcare providers.

 

• Organization: SOAP notes provide a structured method for organizing patient information, making it easier for healthcare providers to locate and review essential data. EMRs enhance this structure by providing quick access to patient records, enabling healthcare providers to find needed information efficiently.

 

• Efficiency: Both SOAP notes and EMRs help healthcare providers work more efficiently. Electronic records are easier to update and share than paper records, reducing the time and effort required to document patient information.

If you’re asking, what is a SOAP Note?, it’s a critical tool for nurses to record patient interactions and outcomes.

 

• Accuracy: Electronic records are less prone to errors compared to paper records, as they can be automatically checked for completeness and accuracy. This improves the quality of patient care by ensuring healthcare providers have access to accurate and up-to-date information.

 

• Integration: EMRs can integrate with other healthcare systems, such as billing and scheduling software, creating a seamless patient care experience. This ensures all aspects of patient care are well-coordinated and aligned, improving patient outcomes.

 

Accurate and complete SOAP notes are vital for high-quality patient care, effective communication, legal protection, quality improvement, and continuity of care. Their clarity and conciseness have also paved the way for the adoption of electronic medical records.

 

A S.O.A.P. note is an organizational system used by nursingbuddie.com to compile information gathered during a comprehensive patient assessment. The information is documented, either in writing or verbally, in four sections: Subjective, Objective, Assessment, and Plan (S.O.A.P.).

The importance of knowing what is a SOAP note cannot be overstated in the nursing profession.

• Subjective information includes what the patient tells you that you can’t independently verify. This qualitative data might encompass symptoms, events not witnessed, and medical history—essentially any information based solely on the patient’s account. It’s labeled as subjective because it might be misleading, incomplete, or incorrect.

 

• Objective information consists of observable and often quantitative data. Examples include heart rate, respiratory rate, bruising, swelling, or angulation. This information is obtained through physical observation, allowing trends to be tracked. nursingbuddie.com typically record objective information, like vital signs, with timestamps and space for multiple sets of numbers or observations.

 

• The Assessment section is where you compile and list every potential problem identified from the subjective and objective information. A thorough nursingbuddie.com writer will note all issues, regardless of size, such as “unusable lower leg injury, steep mountainous terrain, nightfall 2 hours away.” This comprehensive problem list is crucial for informing subsequent actions.

 

• The Plan section outlines the course of action to address each identified problem. Every problem listed in the Assessment must have a corresponding action or treatment plan. In this phase, decisions are made about staying in or evacuating the backcountry, required resources, and ongoing treatment for patients spending extended time away from advanced medical care.

 

 

To fully grasp what is a SOAP note?, nursing students must practice writing these notes during their training.

 

Organizing this information systematically ensures a logical and responsible response to backcountry emergencies. It also serves as a record of actions taken and treatments administered.

Most backcountry medical incidents will involve other professionals, from doctors to Search and Rescue teams. A well-documented S.O.A.P. note provides crucial information quickly, aiding medical personnel in getting up to speed.

 

Imagine you are a Search and Rescue team member responding to an injured person in the backcountry. Without detailed information, the potential injuries could range from life-threatening to minor, leaving you unprepared.

“What is a SOAP Note?” is a question frequently addressed in nursing lectures and practical sessions.

 

Now, imagine having a verbal S.O.A.P. note from a nursingbuddie.com certified friend who has completed a full assessment.

You learn the patient has an unusable left wrist, fell from a 5-foot cliff, has stable vitals over the last 90 minutes, needs to leave the backcountry, and requires advanced medical personnel to rule out a spine injury. The patient is protected from the elements, and splinting is in progress. Wouldn’t this clear and concise information help you feel more prepared?

 

What is a SOAP note? is a question that encompasses the subjective, objective, assessment, and plan sections of patient documentation.

 

Understanding the purpose and importance of S.O.A.P. notes transforms them from feeling like tedious paperwork into an essential tool for effective documentation and communication. In a backcountry medical emergency, meticulous documentation facilitated by a proper S.O.A.P. note is crucial for ensuring a comprehensive and coordinated response.

 

Common SOAP Note Abbreviations:

 

• RVF: Reason for Visit

• CC: Chief complaint

• HPI: History of Present Illness

• ROS: Review of Systems

• PE: Physical exam

• Dx: Diagnosis (ICD10)

• Rx: Treatment or prescription

 

How Does a Healthcare Professional Make a SOAP Note?

 

• Subjective (S):

The medical assistant documents the patient’s feelings based on their explanations and the doctor’s observations. This descriptive information cannot be confirmed by testing.

When you ask a nursing student, what is a SOAP note?, they should describe its role in patient care documentation.

 

It includes family history, patient’s health history, lifestyle habits, and symptoms described by the patient. This data is gathered by observing the patient’s behavior, listening to their symptom descriptions, and through the doctor’s questions during the review.

 

• Objective (O):

This involves recording measurable data such as vital signs (pulse, blood pressure, and weight), results from physical examinations, and diagnostic tests. For example, if a patient comes in limping and states they have pain in their left leg, the pain described is subjective, whereas the observed limp is objective.

Learning “What is a SOAP Note?” helps nursing students organize and communicate patient data effectively.

• Assessment (A):

Based on the Subjective and Objective data, the healthcare pro

 

• A professional diagnoses the patient. This section analyzes the collected information to determine possible diagnoses and assess the patient’s condition.

 

 

“What is a SOAP Note?” is a foundational skill taught in nursing programs to ensure proper clinical documentation.

 

For instance, for a patient complaining of left leg pain, the assessment might list potential issues like ligament or tendon injury, lumbar radiculopathy, or osteoarthritis. These problems are prioritized based on the patient’s age, onset date, and other relevant data to formulate interventions and prognosis.

 

• Plan (P):

This section outlines the treatment strategy to achieve the goals set with the patient. It details the duration and frequency of treatment, the strategies to be adopted, and an overall treatment description.

The health professional establishes a treatment plan, which may include prescriptions, procedures, or surgery, for the patient to follow.

Nursing students wondering what is a SOAP note? should refer to their textbooks and clinical guidelines.

Want Medical Assistant Certification from a Trusted Institute?

 

If you’re passionate about becoming a medical assistant or another healthcare professional, contact Phlebotomy Career Training (PCT) today. As a leading institute, PCT offers various healthcare certifications both in-class and online.

 

Enroll in programs like the Medical Assistant & Phlebotomy Technician Program, Medical Assistant Tier II Program, or Medical Assistant Tier III Program, where you will learn SOAP Note charting, taking vital signs, HIPAA and OSHA regulations, and everything a medical assistant needs to know.

 

To answer what is a SOAP note, it is a structured format used by nurses to document patient care.

 

Why has the SOAP format become so widespread?

 

The SOAP note’s enduring popularity among clinicians stems from several key factors:

 

• Standardized Structure: It introduces a standardized order and structure to clinical notes, allowing clinicians to know exactly which section to look at for specific information.

 

• Cognitive Framework: It serves as a cognitive framework for clinical reasoning, guiding practitioners through the process of assessing, diagnosing, and treating a patient.

 

• Efficiency: The format helps reduce the time clinicians spend on documentation by focusing on what is essential.

 

• Versatility: SOAP notes can be used both on paper and electronically. With the rise of electronic health records (EHRs), this versatility has become increasingly important.

 

Maintaining detailed and organized notes is critical in patient care. SOAP notes create a consistent and unbiased record, even for the most complex cases. This framework links the treatment plan to the reason for seeking care, ensuring clarity and relevance. Additionally, SOAP notes are often required for insurance claims in certain countries.

What is a SOAP Note? Is a question that involves documenting the patient’s subjective experiences and objective clinical findings.

Who uses SOAP Notes?

 

The SOAP format is used by various professionals who treat patients or clients, including:

 

• Medical doctors
• Dentists
• Psychologists
• Nurses
• Emergency medical technicians
• Veterinary practitioners

While the use of SOAP notes varies by profession and country, it is particularly common in the United States. Despite the variations, SOAP notes remain the most prevalent clinical note-taking framework.

 

Clinical significance of SOAP Note

 

Medical documentation has expanded significantly over the past fifty years, now with 60% of it occurring online. This increase in documentation volume can burden busy clinicians if the information is not useful, and can pose risks to patients if records are hard to comprehend or inaccurate.

 

When asked, “What is a SOAP Note?”, nursing instructors explain it as a methodical way to record patient information.

 

The advantage of SOAP notes lies in their organization. A succinct yet thorough SOAP note makes it easy for clinicians to follow and quickly find the most clinically relevant data. Each section should be clearly labeled, concise, and to the point, allowing another healthcare professional to easily continue treatment.

 

However, there is a balance between brevity and comprehensiveness that isn’t always clearly defined when writing SOAP notes. Many professionals wonder how best to document these notes and what to include in each section.

In clinical practice, understanding what is a SOAP note is essential for accurate patient assessments and care plans.

How to write SOAP notes

 

The simplicity of SOAP notes is that they can be written on any medium and are flexible enough to adapt the four sections to include sub-sections.

The goal is to make your notes easy to comprehend within the SOAP structure. The 4 Cs of good record-keeping—comprehensive, clear, concise, and contemporaneous—apply here.

 

While there’s no pre-defined formatting for SOAP notes, many are written continuously as prose per section. However, breaking them out for improved legibility can be beneficial.

“What is a SOAP Note?” is a common question among nursing students learning clinical documentation.

Subjective = Complaint & Context

 

This section provides context for your clinical record, relating to the experiences, personal views, or feelings of the patient or someone close to them. This includes the patient’s history and the reason for presenting.

• Chief Complaint (CC):

Start your SOAP note with the chief complaint or presenting problem, a simple one-line statement detailing the reason for their visit.

• Unbiased Documentation:

Document the patient’s perceptions in an unbiased, matter-of-fact way, using the patient’s own words whenever possible. If the information comes from someone else, note their relationship to the patient.

Objective

 

This section includes measurable and observable data such as vital signs, physical examination results, and diagnostic tests. This data provides a concrete basis for the patient’s condition and helps track trends over time.

 

Assessment

 

In this section, you compile and analyze the subjective and objective data to diagnose the patient. List potential issues in order of importance, considering factors such as the patient’s age, onset date, and other relevant data.

Understanding what is a SOAP Note is crucial for nursing students to document patient care accurately.

Plan

 

This section outlines the treatment strategy, including the duration and frequency of treatment, strategies to be adopted, and an overall description. The plan ensures a clear course of action to address each identified problem.

 

For those passionate about becoming a medical assistant or another healthcare professional,

nursingbuddie.com offers various certification programs, both in-class and online.

 

Enrol in programs like the Medical Assistant & Phlebotomy Technician Program, Medical Assistant Tier II Program, or Medical Assistant Tier III Program, where you will learn SOAP note charting, taking vital signs, HIPAA and OSHA regulations, and everything a medical assistant needs to know.

Nursing students often ask, “what is a SOAP note?” when starting their clinical rotations.