SOAP Subjective, Objective, Assessment, and Plan Unit 3 SOAP in the Patient Medical Record

A SOAP note is described as medical documentation that gives concise and comprehensive information about the patient reasons for acquiring medical attention and is considered a legal document between the patient and the medical facility. The Subjective, Objective, Assessment, and Plan is written and reviewed in all patient medical records including manual paper records and hybrid medical records (EMR - Electronic Medical Record). Any SOAP note can be subpoenaed in a legal court case. A SOAP note is always accurate. If any documentation is not recorded, it did not happen! EMR - Electronic Medical Record Read

The SOAP note should contain a brief statement containing these primary components:  Current Date and Time  Purpose of the Visit - - CC: Chief Complaint  Patient Signs and Symptoms  Observations: Temperature, Pulse, Respirations, Blood Pressure, Height, and Weight. · Current Medications · Current Tx and DX NOTES Read

A SOAP note can also contain miscellaneous information to the Physician Practitioner such as patient questions or telephone assessment. This would also include any telephone calls to the patient in regards to lab or procedural results. A SOAP note will always differ for each specialty and length as well. As you learn to work with SOAP notes you will create your own style or the style preferred in the office or clinic you are working in. It takes time, patience, and practice to become an expert in writing with medical script, such as abbreviations and medical language. When the medical assistant interviews the patient, you will create a picture with words. This will include asking questions such as the when, where and why like color, amounts, or maybe causes. NOTES

A SOAP note will contain two parts with first the medical assistant documentation and then the physician provider documentation. It will appear to be short fragmented sentences only giving the precise information needed that will include 1) current date and time of the discussion, 2) the purpose of the visit or chief complaint of the patient, 3) the patient current signs and symptoms, 4) patient vital signs using the medical office protocol, 5) current medications (prescribed and over-the-counter [OTC]). The medical assistant will concentrate on the Subjective and Objective and the physician provider will follow-up with the Assessment and Plan. NOTES

Since the SOAP note is a legal document a few rules must apply; 1) Patient documentation will begin in the far left side of the margin, 2) Documentation will appear to look like a fragmented sentences or brief and to the point. 3) Never leave an open space between the writing and the right margin of the page. When you complete your SOAP note always draw a line to the right margin only to leave your Initials and credentials to end the line. This will prevent any changes that can be made to the SOAP note. NOTE Read

SOAP Note Example : 6/19/20XX CC: Pt complains of headaches over 4d taking ASA t.i.d. with no relief. OD sensitive to sun and loud noises. Pt complains of nausea throughout the day. BP: 110/72, W: 210. Current meds: ASA OTC, HCTZ 33mg, Xanax 5mg SSample,CMA(AAMA)® NOTE EXAMPLE