How To Properly Document Your Daily In Patient Reviews: SOAP

This article was originally posted on LinkedIn on October 16, 2019 with the original title “Mastering SOAP’s”.

If you’re working in a hospital, you’re likely to be familiar with the acronym SOAP. Which stands for: Subjective Objective Assessment and Plan. This simple acronym is used as a guide in everyday medicine to see and assess the journey of the patient.

Each component is an important aspect of the evaluation of the patient.

Let’s get into it.

When do you use SOAP? 

Often times, this is used after you’ve done a full history and examination and have gone through each component thoroughly, in an effort to find relevant information that will form your diagnosis and guide your plan. SOAPs are more focused and targeted but also allow you to discover new problems and complaints.

Before we get into our SOAP you want to create a problem list, sometimes this is used interchangeably with the diagnosis. Your problem list is literally a list of problems that your patient comes in with, the reason why this is needed is that it guides the rest of your SOAP.

Next you want a list of your medications and then your vitals. The reason I write medications first is because someone once explained to me that you want to see how medications may be affecting a patients vitals. And I have been doing it ever since.

When writing your medications you also want to add whether or not the patient got the medications and for drugs such as antibiotics you should add how many doses. Though not seen here, I usually add a tick to indicate the patient got the medication and an ‘o’ if they didn’t.

For this patient, because of the dehydration, input and output charting could also be included in the vitals.

It’s important not to forget your identifying information for the patient, each sheet of paper tends to have a location for you to put this.

I also like to write how many days a patient has been admitted to hospital.

Now that we have headed up our page it’s time to get into the SOAP.

Subjective

This is everything that the patient tells you, often times you break the ice with the patient and ask “any complaints?” most times I don’t find this approach sufficient and many patients need prompts. In our example case we see that the patient has a community acquired pneumonia, they’re on antibiotics, nebulisation and cough medication… we also notice they have been febrile and tachycardic. So we ask specific questions after our open ended one… “how is the cough?” “what colour is the sputum?” “are you having chills?” “do you feel your heart beating really fast?”. We are asking specific questions tailored to the patient in order the see whether they are improving or not.

Objective

This is where we do our examination. Since a more in-depth examination was done when the patient first presented, we do a much more focused one. This examination will focus the systems that our problems may be affecting. The respiratory system, a general examination and possibly the cardiovascular system should be paid keen attention to.

Even though focused, each system should be examined everyday.

Under objective I also write any results I may be privy to at that time.

Assessment:

With all the information that you have gathered you’re going to put it all together and decide what it all means. In my assessment I like to put back the problem list and make a comment on each as well as add new problems. I say be as detailed as you can with this because it will eventually guide your plan and make it easier not to forget anything.

Plan:

This is guided by your assessment, I like to go one by one when creating my plan, this way I’m unlikely to forget something that might be important. Your plan will be made based on best practices and guidelines, however, often times treatment of patients comes down to what is available in your setting. Even so, we are always practicing evidence based medicine.

I always like to close my notes with my signature, my name and my position.

I am not sure if there is a one way or a right way to do SOAPs, I have found that the way I like to do mine is influenced by working with several doctors. At the end of the day, a SOAP is merely a template for how to see patients day to day, to map progress and quickly pick up problems. What I have given is the bare minimum SOAP that can be built on. Even while writing this I can think of ways to improve my own example SOAP.

Now that I have shared my tips and tricks, I’d like to know yours, how do you ‘master SOAPs’?

Just because…

Possible Improvements:

1. I would add the patients age when I headed up the page.
2. Use less abbreviations, though usually understood, sometimes abbreviations (even when standardised) can be confusing. 
3. Write a range of specific vitals, in this case temperature and blood pressure especially. 
4. In my examination write certain vitals such as respiratory rate and pulse that I get and not just from the nurses notes. (I usually do this when I see abnormal results)
5. Add a central nervous system examination… just to quickly comment on the patient’s mental status at the time of the interview.

Dr. Samantha C. Johnson.

Photo by Aaron Burden on Unsplash