Match the content for each area of the soap chart notes with the appropriate description.

September 10, 2015   |   Evidence in Integrative Healthcare

In a previous post, we reviewed the necessity of basic best practices for SOAP notes including legibility, identification, and dated chart entries. In this post, we review the proper structure and contents of a SOAP note.

The acronym SOAP stands for Subjective, Objective, Assessment, and Plan. Each category is described below:

S = Subjectiveor symptoms and reflects the history and interval history of the condition. The patient’s presenting complaints should be described in some detail in the notes of each and every office visit. Using the patient’s own words is best. Routine use of one-word entries or short phrases such as “better”, “same”, “worse”, “headache”, “back pain” is usually not sufficient. In follow-up notes, “S” is a reiteration of the chief complaints elicited during the initial evaluation of the patient. The complaints should reflect change over time. The patient’s responses to the previous treatment, resumption of daily or occupational activities, intervening injuries, and exacerbations are also noted in “S.”

“S” should also describe improvement in the patient’s activities and physical capacities in the interim since the last treatment. Also included in this section are explanations for any hiatus in treatment and the patient’s compliance with recommended home care.

O = Objective or observations. This section includes inspection (e.g., “patient still walks with antalgic gait”) as well as a more formalized reevaluations such ranges of motion, provocative tests, specialized tests (fixations, tongue, pulse, BP, labs). The extent of the reevaluation at each office visit is determined by the information gathered in “S” together with the original positive clinical findings as well as changes in “O” at previous office visits. Usually only the critical indictors need be repeated. Findings should be qualified and quantified in order to be able to ascertain progress/response to care over time. Indicators for treatment should always be identified in order to document necessity of the treatment provided and described in “Plan” section of the note, for example motion palpation findings, stagnation of blood and chi, or abnormal lab values.

A = Assessment. Initially this is the diagnostic impression or working diagnosis and is based the “S” and “O” components of SOAP. On follow-up visits the “A” should reflect changes in “S” and “O” as a response to time, treatment, and other interim events (e.g., “Cervical strain, resolving” or “exacerbation of right sacroiliac pain”). “A” should be continually updated to be an accurate portrayal of the patient’s present condition. Other components of “A” may include the following where appropriate: patient risk factors or other health concerns, review of medications, laboratory or procedure results, and outside consultation reports.

P = Planor Procedure. The initial plan for treatment should be stated in “P” section of the patient’s first visit. A complete treatment plan includes treatment frequency, duration, procedures, expected outcomes and goals of treatment. An initial treatment plan may be for an initial trial of treatment over a short interval with a re-assessment and further treatment planning at that later time.

On each follow-up visit, “P” should indicate modalities and procedures performed that day, continuation or changes in the overall treatment plan. “P” should also describe what the patient is to do between office visits, what the expected course of treatment is, what further tests might be ordered (e.g., “Obtain cervical MRI if upper extremity paresthesia persists”), and the disposition of the case (discharge, referral, etc.). It is also appropriate to include in this section any comments with respect to the patient’s compliance.

Other items or events to be charted include:

• Any phone or personal contact with the patient.
• Missed appointments, rescheduled appointments, or when the patient is significantly late for an appointment.
• The receipt of important correspondence regarding the case.
• Requests for medical records sent or received.
• Transmittal of records, correspondence, etc.
• X-rays and other imaging studies, lab work, consultation reports.

Facing SOAP oral presentations may cause a number of symptoms in the uninitiated M3: racing heart, rollercoaster gut, and sweaty palms. As with many first-time experiences you’ll encounter in your third year, preparation goes a long way toward surviving SOAP oral presentations.
But first, let’s make sure we’re clear on an important point.

SOAP presentations and notes vs. the other SOAP

As a med student, you’ll hear about two different SOAPs. One involves the Match and sometimes has its own nerve-racking associations. The SOAP we’re referring to now, though, stands for a very useful note-taking format:
S – subjective (how the patient feels)
O – objective (vitals, physical exam, labs)
A – assessment (brief description of how the patient presented and a diagnosis)
P – plan (what will be done to treat the patient)
The SOAP notes format is a standard method for giving patient information. You’ll find it effective for both writing notes and presenting patients on rounds.

SOAP oral presentations on rounds

During your clerkship, at some point you’ll be expected to present a patient to discuss on rounds. You’ll most likely present to nurses, residents, and attending physicians who are there to hear from you about what’s going on with the patient. Knowing that, you’ll want your information to be correct, well-organized, and concise. The SOAP format can help.

For the subjective segment, lead with a one-sentence reminder of who your patient is. Give an overview of how your patient did overnight and anything major that may have happened since you last rounded.

Open this segment by discussing vital signs, including blood pressure, pulse, respirations, temperature, and oxygen saturations. Next, present I/Os: intakes and outputs. Give the total intake, followed by a breakdown. Then present your exam, and after that, give laboratory results. If there’s something notable about the labs compared to the day before, make sure to point it out. Sometimes, there will be pertinent imaging that can be presented here as well.

Assessment Notes

This is essentially a wrap-up of the subjective and objective portion of the presentation, so you’ll want to keep it brief. In fact, while on rounds, you might want to listen for the team’s overall impression of the patient and put it into one sentence. The assessment is where you’ll want to avoid too much repetition.

Plan Notes

Here’s where you’ll discuss what you’re actually going to do for your patient. When it comes to the plan, it can be challenging to know how much detail to go into. One of the best things you can do is ask a resident to take a look at your plan, and then ask their advice on how much to present. It can save you time and frustration in the long run.

• Learn what your attendings prefer. When in doubt, ask your attendings on your first day how much detail they like in their presentations. Different attendings want you to present differently—with some wanting you to go over your whole note in detail and others just wanting you to get to the point as quickly as possible.
• Keep your presentations brief. That may depend on just how much detail your attending wants. But generally, a concise and well-organized presentation means you’ll want to shoot for about five minutes. Of course, answering questions may add more time, so be prepared for that.
• Don’t forget to breathe. No doubt, presenting patients can be stressful at first. But that’s where the SOAP format can help. Stick with that, take a deep breath, and over time you’ll find yourself handling oral presentations like a pro.

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