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Steps to Writing a SOAP Note

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by

Tonya Smith

on 10 May 2016

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Transcript of Steps to Writing a SOAP Note

The Steps to Writing a SOAP Note
Questions?
Subjective
Objective: Vitals, Physical Exam
Subjective or Objective???
Assessment
Plan
Assessment/Plan
ALWAYS include Health Maintenance
(immunizations, cancer screenings, smoking cessation).
Weight may also be included in this category.
References
Guidelines

Clinical trials

Websites
Heading
Signature, title
Content
Point distribution
Miscellaneous
Anything reported by patient
Review of Systems
Home testing results (unless have meter/monitoring with them)
Meds as reported by patient
Complaints reported by patient
Diet/Exercise
Social history, family history, PMH
Anything you would have to trust the patient with
Allergies
Deductions:
Items in the wrong section
Missing dose, frequency, medication on medication list
Problem list
Evidence for problem/guidelines
Goals of therapy
Assessment of changes
Health maintenance
What is your assessment of the patient's current status?
NOT what you plan to do, just ASSESS

Systems based physical exam
Vital exams taken by YOU/nurse/doctor
Studies (EKG, x-rays, CT scans, pending tests
Medication info
Allergy info
Immunizations from patient chart
Information you can verify/have witnessed/assessed during examination or hospital stay
Information can go in both S/O?
BP taken upon arrival
Medication List patient brought
Family History
Alcohol use
Lab values
Diet/exercise
Drug therapy
Non-rx therapy
Monitor parameters/frequency
Scheduled follow-up
Evidence to support
Counseling given
Alternate plan
Recommendations made/conversation with patient
SPECIFIC
Full transcript