When writing your SOAP note base the note off of the information provided to you.
When writing your SOAP note base the note off of the information provided to you. Make sure the diagnosis fits the symptoms provided to you in the case materials. It is possible the initial/provisional diagnosis may change as you know more about the client. This additional information about the client can come from the client, family, friends, or other collateral sources. Of course a release of information would be required to obtain collateral information. Diagnosis should be based from a holistic perspective, looking at multiple aspects of the client's life. For example has there been any recent changes in the client's life (environment, school, expectations, social/friends, family, and responsibilities). If yes, it is likely there could be issues with adjusting.
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DQ#5 In Topic 5, you created a treatment plan for your client. Create a SOAP note that would go in the client’s chart following the visit. Post the SOAP note as a reply to this discussion thread. For follow-up discussion, evaluate at least two of your peers' SOAP notes. Would you have documented anything differently? Why or why not?
A SOAP note is a form of written documentation many healthcare professions use to record a patient or client interaction. Because SOAP notes are employed by a broad range of fields with different patient/client care objectives, their ideal format can differ substantially between fields, workplaces, and even within departments. However, all SOAP notes should include Subjective, Objective, Assessment, and Plan sections, hence the acronym SOAP. A SOAP note should convey information from a session that the writer feels is relevant for other healthcare professionals to provide appropriate treatment. The audience of SOAP notes generally consists of other healthcare providers both within the writer’s own field as well in related fields but can also include readers such as those associated with insurance companies and litigation. A good SOAP note should result in improved quality of patient care by helping healthcare professionals better document and therefore recall and apply details about a specific case.
How long is a SOAP note and how do I style one?
The length and style of a SOAP note will vary depending on one’s field, individual workplace, and job requirements. SOAP notes can be written in full sentence paragraph form or as an organized list of sentences fragments. Note the difference in style and format in the following two examples. The first come from within a hospital context. The second is an example from a mental health counseling setting.
S – Nauseated, fatigued
O – Less jaundiced
Liver less tender
Taking adequate calories and fluid
Ultrasound liver/billary tract: normal
A – Seems to be improving
P – Check liver tests tomorrow
Phone laboratory for hepatitis markers
(from Heifferon, 2005, p. 103)
7/7/01 2 p.m. (S) Reports counseling is not helping him get his family back. Insists the use of violence has been needed to “straighten out” family members. Reports history of domestic violence. Recent history: States he met and verbally fought with his wife yesterday regarding the privileges of oldest child. Personal history: childhood physical and mental abuse resulting in foster care placement, ages 11-18. (O) Generally agitated throughout the session. Toward the end of the session stood up, with clenched fists and jaw, angrily stated that counseling is “same old B.S.!” Rushed out of office. (A) Physical Abuse of Adult [V61.1 DSM code] and Child(ren) [V61.21]. Clinical impressions: rule out Intermittent Explosive Disorder given bouts of uncontrolled rage with non-specific emotional trigger. (P) Rescheduled for 7/14/01 @ 2 p.m.; Continue cognitive therapy. Refer to Men’s Alternatives to Violence Group.
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