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SOAP Notes

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by

Megan Maralit

on 6 February 2014

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Transcript of SOAP Notes

SOAP Notes
Importance of SOAP notes
SOAP notes are very important because without them doctors would not know what previous doctors did. They contain every important piece of information doctors need. Without them, "it didnt really happen" so that is why it is important for doctors to take very accurate and informed notes.
Subjective
S in SOAP stands for Subjective.
In this area of the notes is where what the patient says is put. Such as the reason they are there, complaints, severity, the onset, if they have taken anything for it, if anything is making it worse and any symptoms.
Objective
The O in SOAP stands for objective.
This is where any tests, results, findings, vital signs, measurments(weight/height), blood pressure, heart rate, etc. go. Most likely, anything tangible goes here.
Touch, Smell, Hear or See
Assesment
The A in SOAP stands for Assesment. it is where the doctor looks and observes the items written in the objective and diagnosis the problem. It can including the right diagnosis or possiblites of diagnosis'.
Plan
Lastly, the P in SOAP stands for Plan. This is where the plan for the patient that the doctor decided. This could be a procedure, taking any medications, or anything that helps make the situation better.
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