Introduction:

The SOAP Note Template is a documentation method used by medical practitioners to assess a patient's condition.  It is commonly used by doctors, nurses, pharmacists, therapists, and other healthcare practitioners to gather and share patient information.

Developed by Dr/ Lawrence Weed in the 1960s, the SOAP Note Template methodology records vital patient medical information, to provide evidence of patient contact, and to inform a clinical reasoning process.

SOAP notes have four main parts, designed to help improve evaluations and standardize documentation:

  • Subjective - What the patient tells you
  • Objective - What you see
  • Assessment - What you think is going on
  • Plan - What you will do about it

This SOAP Note Template will act as your guide, to assist you in the creation of a SOAP Note Template. By using this template, you will conduct clear and concise documentation of patient information. This will help the involved practitioner get a better overview and understanding of the patient's needs and concerns. 

How to use this checklist

At the beginning of this checklist, you will be presented with a set of specialized questions given as form fields. You are required to populate each form field with your data.

The SOAP process is split into four basic steps:

  • Subjective
  • Objective
  • Assessment
  • Plan

At the end of each stage, your supervisor/manager will review your work using Process Street's approvals feature. The resulting information is then used to make system improvements. The best way to apply the results will depend on the nature of the system.

    Features used in this template include: 

    • Stop tasks - To ensure task order.
    • Dynamic due dates - To make sure your initiative is reviewed on time.
    • Role assignment - To delegate tasks within your team ensuring your supervisors are appropriately assigned to the review tasks.
    • Approvals - Tasks can be accepted, rejected, and rejected with comments.

    Record checklist details

    In this SOAP Note Template, you will be presented with the following form fields which you are required to populate with your specific data. More information for each form field is provided via linkage to our help pages:

    Let's start by recording your details, patient details, and the details of your supervisor or manager.

    This is a stop task, meaning you cannot progress in this template until the required form fields are populated.

    Your details
    Patient details
    Details of Manager/Supervisor

    Subjective:

    Document what the patient tells you

    The subjective section refers to what the patient tells you. Use the long-text form field below to detail the chronological complaints given by the patient.

    Next you are presented with the subtask form field. Check off each task in this subtask list to confirm you have consulted the required documentation.

    Consult:

    • 1
      The patient's medical history
    • 2
      The patient's surgical history
    • 3
      The patient's social history
    • 4
      Current medications
    • 5
      Information obtained from other sources

    You can summarize important information using the long-text form field below.

    Objective:

    Document your observations of patient vital signs

    This next section concerns observations made by the clinician. That means making a physical observation of the patient's general appearance and take into account vital signs such as temperature and blood pressure.

    Use the long-text form field below to record important vital signs.

    Make sure to include the following during your observations:

    • 1
      Vital signs including oxygen saturation when indicated
    • 2
      Focus on physical exam
    • 3
      All pertinent labels, x-rays, etc, completed at the visit

    Assessment:

    Document your assessment results

    In the assessment phase, a diagnosis is carried out to determine what condition the patient has.

    This assessment is based on the findings indicated in the subjective and objective sections. This is ideally a one-sentence description of the patient and major problem.

    Use the short-text form field below to document your assessment.

    When conducting your assessment make sure to include:

    • 1
      Diagnostic tests
    • 2
      Referral to other specialists

    Next create a problem list, which is a numerical list of the problems identified.

    All listed problems need to be supported by findings in subjective and objective areas.

    Try to take the problem to the highest level of diagnosis that you can.

    Plan:

    Document your treatment plan

    Once you have addressed the patient's problem, elaborate on a treatment plan indicating medication, therapies, and surgery needs.

    Use the long-text form field below to document the patient's plan.

    When documenting the treatment plan, be sure to consider:

    • 1
      Additional tests that may be needed
    • 2
      Follow up consultations
    • 3
      Laboratory studies

    Your treatment plan should include:

    • 1
      Patient education
    • 2
      Procedures
    • 3
      Pharmacotherapy if any
    • 4
      Other therapeutic procedures
    • 5
      Addressed plans for follow up

    SOAP assessment results:

    View assessment results

    Your SOAP assessment results are summarized and detailed below. These results are subject to review and approval by your relevant manager.

    Results

    Subjective

    {{form.Patient_states}}

    {{form.Summarize_patient_information}}

    Objective

    {{form.What_you_see}}

    Assessment

    {{form.What_you_think_is_going_on_2}}

    {{form.Problem_list}}

    Pan

    {{form.Treatment_plan}}

    Approval: Results review

    Will be submitted for approval:
    • View assessment results
      Will be submitted

    Sources:

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