NSG 6435 Week 1 Project SOAP Note

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NSG 6435 Week 1 Project SOAP Note

NSG 6435 Week 1 Project SOAP Note

 

Each week, you are required to enter your patient encounters
into medley. Your faculty will be checking to ensure you are seeing the right
number and mix of patients for a good learning experience. You will also need
to include a minimum of one complete SOAP note using the Pediatric SOAP Note
template. The SOAP note should be related to the content covered in this week, and
the completed note should be submitted to the Dropbox. When submitting your
note, be sure to include the reference number from eMedley.

Submission Details:

By the due date assigned, enter your patient encounters into
eMedley and complete at least one SOAP note in the template provided.

Name your SOAP note document
SU_NSG6435_W1_A3_LastName_FirstInitial.doc.

Include the reference number from eMedley in your document.

Submit your document to the Submissions Area by the due date
assigned.

How To Write Therapy SOAP Notes

Therapy SOAP notes follow a distinct structure that allows medical and mental health professionals to organize their progress notes precisely.[1]

As standardized documentation guidelines, they help practitioners assess, diagnose, and treat clients using information from their observations and interactions.

Importantly, therapy SOAP notes include vital information on a patient’s health status. This information can be shared with other stakeholders involved in their wellbeing for a more informed, collaborative approach to their care, as shown:

HIPAA-compliant therapy software will store and share SOAP notes in a secure, private way to protect practitioners and patients. (Pictured: Quenza)

It’s critical to remember that digital SOAP notes must be shared securely and privately, using a HIPAA-compliant teletherapy platform. Here, we used Quenza.

The S.O.A.P Acronym

SOAP is an acronym for the 4 sections, or headings, that each progress note contains:

  1. Subjective: Where a client’s subjective experiences, feelings, or perspectives are recorded. This might include subjective information from a patient’s guardian or someone else involved in their care.

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  2. Objective: For a more complete overview of a client’s health or mental status, Objective information must also be recorded. This section records substantive data, such as facts and details from the therapy session.
  3. Assessment: Practitioners use their clinical reasoning to record information here about a patient’s diagnosis or health status. A detailed Assessment section should integrate “subjective” and “objective” data in a professional interpretation of all the evidence thus far, and
  4. Plan: Where future actions are outlined. This section relates to a patient’s treatment plan and any amendments that might be made to it.

A well-completed SOAP note is a useful reference point within a patient’s health record. Like BIRP notes, the SOAP format itself is a useful checklist for clinicians while documenting a patient’s

NSG 6435 Week 1 Project SOAP Note

NSG 6435 Week 1 Project SOAP Note

therapeutic progress.[2]

In the next section, you’ll find an even more in-depth template for SOAP notes that can be used in a wide range of therapeutic sectors.

Therapy SOAP notes include vital information on a client’s health status; this can be shared with other stakeholders for more informed, collaborative patient care.

3 Helpful Templates and Formats

With a solid grasp of the SOAP acronym, you as a practitioner can improve the informative power of your Progress Notes, as well as the speed with which you write them. 

This generally translates into more one-on-one patient time, reduced misunderstandings, and improved health outcomes overall – so the table below should be useful.

SOAP Notes: A Step-By-Step Guide

Podder and colleagues give a great overview of the different subsections that a SOAP progress note can include. Based on their extensive article, we’ve created the following example that you can use as guidance in your work.[1]

Details
Subjective

 

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