SOAP notes provide a summary of patient symptoms, nurse observations of the patient and describe a treatment plan in detail, as Gap Medics reports. The SOAP note format is used in clinical rounds and includes four sections.Continue Reading
Each SOAP note section provides an objective means of recording and sharing specific information about the patient. SOAP notes list any symptoms that are present and describe the treatment plan suggested for the patient's care, as Gap Medics claims.
The subjective section describes the symptoms reported by the patient, when the symptoms began and what alleviates the patient's symptoms. Next, the objective section provides measurable facts about the patient's condition such as vital signs, body temperature and the results of lab tests. The assessment section lists the patient's diagnosis or offers possible diagnosis information. Finally, the plan section provides a treatment strategy for the patient.
Taking notes during rounds helps nurses write better SOAP notes. Irrelevant information should be excluded, and the SOAP notes should be consistent and objective. Medical abbreviations may help summarize the notes by using fewer words to express conditions and symptoms. Since the notes are written for a medical and nursing audience, medical terminology may be used whenever necessary to clarify information, as Gap Medics suggests.Learn more about Careers