Understanding SOAP format for Clinical RoundsJanuary 2, 2015
When you start your clinical rotations in medical school, at some point, you will have to present a patient to discuss at rounds. The team including nurses, residents and attending physicians, will listen to your presentation to get an idea of what is going on with the patient. The information needs to be correct, well organized and concise.
In order to facilitate a standard method for providing patient information, clinicians use the SOAP format for both writing notes and presenting patients on rounds.
What is a SOAP Note?
A SOAP note is information about the patient, which is written or presented in a specific order, which includes certain components. SOAP notes are used for admission notes, medical histories and other documents in a patient’s chart. Many hospitals use electronic medical records, which often have templates that plug information into a SOAP note format. Most healthcare clinicians including nurses, physical and occupational therapists and doctors use SOAP notes. As a med student, you also need to use a SOAP note format.
The purpose of a SOAP note is to have a standard format for organizing patient information. If everyone used a different format, it can get confusing when reviewing a patient’s chart. A SOAP note consists of four sections including subjective, objective, assessment and plan.
What Each Section of a SOAP Note Means
Each section of a SOAP note requires certain information, including the following:
Subjective: SOAP notes all start with the subjective section. This refers to subjective observations that are verbally expressed by the patient, such as information about symptoms.
It is considered subjective because there is not a way to measure the information. For example, two patients may experience the same type of pain. One patient may report it as the worst pain of their life while another may say it was only moderate pain.
When considering what to include in the subjective section of your SOAP notes remember the mnemonic OLDCHARTS. Each letter stands for a question to consider when documenting symptoms. Consider the following:
– Onset: Determine from the patient when the symptoms first started.
– Location: If pain is present, location refers to what area of the body hurts.
– Character: Character refers to the type of pain, such as stabbing, dull or aching.
– Alleviating factors: Determine if anything reduces or eliminates symptoms and if anything makes them worse.
– Radiation: In addition to the main source of pain, does it radiate anywhere else?
– Temporal patterns: Temporal pattern refers to whether symptoms have a set pattern, such as occurring every evening.
– Symptoms associated: In addition to the chief complaint, determine if there are other symptoms.
Objective: The second section of a SOAP note involves objective observations, which means factors you can measure, see, hear, feel or smell. This is the section where you should include vital signs, such as pulse, respiration and temperature. Information from a physical exam including color and any deformities felt should also be included. Results of diagnostic tests, such as lab work and x-rays can also be reported in the objective section of the SOAP notes.
Assessment: The next section of a SOAP note is assessment. An assessment is the diagnosis or condition the patient has. In some instances, there may be one clear diagnosis. In other cases, a patient may have several things wrong. There may also be other times where a definitive diagnosis is not yet made, and more than one possible diagnosis is included in the assessment.
Plan: The last section of a SOAP note is the plan, which refers to how you are going to address the patient’s problem. It may involve ordering additional tests to rule out or confirm a diagnosis. It may also include treatment that is prescribed, such as medication or surgery. The plan may also include information for self-care and deposition including bed rest and days off work.
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Tips for Using SOAP Note Format during Rounds
The SOAP note format may seem quite involved, and it can be. But using the format does not have to be overwhelming. In fact, using a set format is meant to make things easier and better organized. Keep in mind, you may be writing SOAP notes for charting purposes, but you will also use it as a guide when you are doing an oral presentation on a patient.
There are several things you can do to use SOAP notes effectively and present your cases during clinical rounds in a competent manner.
Write thorough notes you can refer to during rounds. You cannot expect to remember specific things about each patient, such as lab values and vital signs. It is acceptable to refer to your notes.
Before you write your notes, organize your thoughts. For example, you do not need to write everything in the same order the patient reported it. Take a few minutes and think about what you need to include and in what order you want to write.
Omit contributory information. You will have enough information to report and adding information, which is not relevant to the situation does not help. For example, if you patient reports they do not have pain, you do not need to quote their exact statement.
Remember you are writing and presenting your case for other healthcare professionals not the general public. It may be acceptable to use medical terminology in many cases. If your notes are going to be part of the patient’s permanent record, make sure you know what abbreviations are acceptable. If you are just writing to have something to reference when you present a case, you whatever abbreviations you choose.
When presenting your case, aim for about five minutes. If you are concise and well organized, you should be able to present a case in about five minutes. Prepare to answer questions, and if you don’t know the answer, don’t make it up.
Take a deep breath. Presenting cases during rounds can be a bit stressful, especially at first. But using the SOAP format can help. Take a deep breath, and before you know it presenting cases will become second nature.