Question

i need to write a old chart soap note for NP

Answer 1

The Subjective, Objective, Assessment and Plan (SOAP) note is an acronym representing a widely used method of documentation for healthcare providers. The SOAP note is a way for healthcare workers to document in a structured and organized way.

This widely adopted structural SOAP note was theorized by Larry Weed almost 50 years ago. It reminds clinicians of specific tasks while providing a framework for evaluating information. It also provides a cognitive framework for clinical reasoning. The SOAP note helps guide healthcare workers use their clinical reasoning to assess, diagnose, and treat a patient based on the information provided by them. SOAP notes are an essential piece of information about the health status of the patient as well as a communication document between health professionals. The structure of documentation is a checklist that serves as a cognitive aid and a potential index to retrieve information for learning from the record.

Subjective

This is the first heading of the SOAP note. Documentation under this heading comes from the “subjective” experiences, personal views or feelings of a patient or someone close to them. In the inpatient setting, interim information is included here. This section provides context for the Assessment and Plan.

Chief Complaint (CC)

The CC or presenting problem is reported by the patient. This can be a symptom, condition, previous diagnosis or another short statement that describes why the patient is presenting today. The CC is similar to the title of a paper, allowing the reader to get a sense of what the rest of the document will entail.

    Examples: chest pain, decreased appetite, shortness of breath.

However, a patient may have multiple CC’s, and their first complaint may not be the most significant one. Thus, physicians should encourage patients to state all of their problems, while paying attention to detail to discover the most compelling problem. Identifying the main problem must occur to perform effective and efficient diagnosis.

History of Present Illness (HPI)

The HPI begins with a simple one line opening statement including the patient's age, sex and reason for the visit.

    Example: 47-year old female presenting with abdominal pain.

This is the section where the patient can elaborate on their chief complaint. An acronym often used to organize the HPI is termed “OLDCARTS”:

•     Onset: When did the CC begin?
•     Location: Where is the CC located?
•     Duration: How long has the CC been going on for?
•     Characterization: How does the patient describe the CC?
•     Alleviating and Aggravating factors: What makes the CC better? Worse?
•     Radiation: Does the CC move or stay in one location?
•     Temporal factor: Is the CC worse (or better) at a certain time of the day?

    Severity: Using a scale of 1 to 10, 1 being the least, 10 being the worst, how does the patient rate the CC?

It is important for clinicians to focus on the quality and clarity of their patient's notes, rather than include excessive detail.

History

    Medical history: Pertinent current or past medical conditions
    Surgical history: Try to include the year of the surgery and surgeon if possible.
   Family history: Include pertinent family history. Avoid documenting the medical history of every person in the patient's family.
   Social History: An acronym that may be used here is HEADSS which stands for Home and Environment; Education, Employment, Eating; Activities; Drugs; Sexuality; and Suicide/Depression.

Review of Systems (ROS)

This is a system based list of questions that help uncover symptoms not otherwise mentioned by the patient.

    General: Weight loss, decreased appetite
    Gastrointestinal: Abdominal pain, hematochezia
    Musculoskeletal: Toe pain, decreased right shoulder range of motion

Current Medications, Allergies

Current medications and allergies may be listed under the Subjective or Objective sections. However, it is important that with any medication documented, to include the medication name, dose, route, and how often.

    Example: Motrin 600 mg orally every 4 to 6 hours for 5 days

Objective

This section documents the objective data from the patient encounter. This includes:

•     Vital signs
•     Physical exam findings
•     Laboratory data
•     Imaging results
•     Other diagnostic data
•     Recognition and review of the documentation of other clinicians.

A common mistake is distinguishing between symptoms and signs. Symptoms are the patient's subjective description and should be documented under the subjective heading, while a sign is an objective finding related to the associated symptom reported by the patient. An example of this is a patient stating he has “stomach pain,” which is a symptom, documented under the subjective heading. Versus “abdominal tenderness to palpation,” an objective sign documented under the objective heading.

Assessment

This section documents the synthesis of “subjective” and “objective” evidence to arrive at a diagnosis. This is the assessment of the patient’s status through analysis of the problem, possible interaction of the problems, and changes in the status of the problems. Elements include the following.

Problem

List the problem list in order of importance. A problem is often known as a diagnosis.

Differential Diagnosis

This is a list of the different possible diagnosis, from most to least likely, and the thought process behind this list. This is where the decision-making process is explained in depth. Included should be the possibility of other diagnoses that may harm the patient, but are less likely.

    Example: Problem 1, Differential Diagnoses, Discussion, Plan for problem 1 (described in the plan below). Repeat for additional problems

Plan

This section details the need for additional testing and consultation with other clinicians to address the patient's illnesses. It also addresses any additional steps being taken to treat the patient. This section helps future physicians understand what needs to be done next. For each problem:

    State which testing is needed and the rationale for choosing each test to resolve diagnostic ambiguities; ideally what the next step would be if positive or negative

•     Therapy needed (medications)
•     Specialist referral(s) or consults
•     Patient education, counseling

A comprehensive SOAP note has to take into account all subjective and objective information, and accurately assess it to create the patient-specific assessment and plan.

Writing a SOAP Note Step By Step
It is important to note that documentation plays a major role in the process of providing health care services. However, in most cases, this aspect is highly ignored since most of health care providers choose to adopt methods that are not specific and sometimes giving a very brief description that is quite vague making it for another person to even comprehend.
In as much as there is no guidance on the length and details of patient’s information that should be documented, one should understand that they need to provide enough and relevant information based on the case at hand. The following are some of the guidance given by the American Physical Therapy Association on the nature of the information that should be included in a patient’s documentation:

•     The patient’s self-report
•     The details of the kind of intervention given
•     The used equipment
•     Patients response
•     Any complication or negative reactions
•     Factors that lead to an intervention change
•     Achievement of goals or objectives stated
•     Proper communication with other stakeholders i.e., health providers or the patient’s family.

As a health provider, you should always have in mind that your report will at one-point land in the hands of another health provider either when you are still handling that case or some years later when the patient seek health assistance. This, therefore, calls you to be cautious to ensure that you write it well. We have already mentioned the components of a SOAP note, it now time to have an in-depth look at them.

Writing the Subjective
In simple terms, this is the information provided by the patient in a narrative form about their problem in terms of the symptoms, disability, function, and history. It is therefore very detailed. This information not only comes from the patient, it can also be derived from other caregivers or family members.
Direct phrases should be used to quote exact phrasing in this case. The purpose of this component is to allow the health officer to document what the patient’s think about their condition in regards to their functional performance, rehabilitation progress or their quality of life. The following are some of the major things that you can find in the Subjective part of the SOAP note:

•     c. standing for (Chief Complaint)
•     description of pain
•     Etiology MOI (Mechanism of Injury)
•     Patient’s History

Points to note:

• This is the most important part of a SOAP notes as it will help you in the objective part when trying to get to the exact potential injury.
• Make sure you completely avoid any question that will result in a YES or NO answer.
• Do not pre-judge on the patient, for example, thinking that the patient is overreacting
• Make sure you only capture the relevant information. Don’t include information such as a patient’s complaint about the last therapist

Writing the Objective
This section includes anything that you observe as the health officer. Such aspects can be measurable. It should all the intervention measures such as the duration, frequency, and the used equipment. As the health officer, you need to document how the patient reacts to these interventions not forgetting their communication with the family or colleagues.
Some of the things that don’t miss out in the objective section are:

•     ROM (Range of Motion)
•     Circulation
•     Palpation – soft and bony
•     Vision
•     Manual muscular tests
•     Special tests

Points to note:

• All special tests should be highlighted at this point
• Make sure you identify the possible injury here so that you can picture what the main problem
• Provide enough details
• Avoid the use of general intervention such as ROM since we have Active, Passive and Resistive Range of Motion.

Writing Assessment
This is another important part of the SOAP note as it involves the professional opinion of the health care provider based on both the subjective and objective findings. Here you need to provide a clear explanation of what made you choose one intervention over the other. You also need to provide the patient’s progress towards the objectives or goals set and also include any factor that negatively affects this progress and needs to be modified in terms of the frequency, duration or the entire intervention. You should also not forget to include any adverse or positive response.
Points to note:

• Avoid being general in the assessment as it will make it look vague. For example, stating that the patient is improving
• Provide enough insight on any issue

Writing the Plan
This is the last part of the SOAP note and it is about the interventions for the patient’s treatment. This should have the various types of treatment that the patient should be given such as the therapies, medication, and surgeries.
Make sure you include both the long-term and short-term plans. For long -term plans, you can recommend the patient to change his/her lifestyle.
This section can also contain the outcome that you expect to see from the patients based on the treatment provided. This includes things such as increase strength, pain reduction or ROM.
Points to Note:

•     The plan is a guide that should be referred to on a daily basis until the treatment goals are achieved.
•     There should be no vague description in the plan.
•     Ensure that the upcoming plan is included

Tips on Writing a SOAP Note
Having gone through the basic facts of the components of SOAP note, here are some brief tips on how to develop an excellent SOAP note.

• Make sure you follow the prescribed format, you SOAP note should start from the subjective, and then the objective followed by the assessment and conclude with the plan. This will ensure that your note is effective.
• Your SOAP not should be as clear and concise as possible. This is to say it should be brief enough but capture all the relevant information that sufficiently informs about the patient’s problem.
• It should be well-organized so that anyone else who will pick it up will have no challenges in understanding it.
• Only consider important or significant information.
• When using medical terms, ensure that they are ones that everyone in your institution is familiar with.

Having said that, here are some of the best practices in writing SOAP notes:

• SOAP notes should be legible, simple, concise and easily understandable
• SOAP notes should strictly follow the prescribed template
• SOAP notes should include only the relevant information
• The subjective part of the note should be captured immediately after the patient has explained his/her condition.

These are some of the things that are not expected from you while writing a SOAP note:

1. Including irrelevant information
2. Using medical terms that people in the medical field are not familiar with

•     Including vague or uncertain information

1. Having a long and an exaggerated SOAP note that does not follow the template.