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 eMedley. 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.

What’s the SOAP note definition?

 

soap note definition
(Source)

SOAP (subjective, objective, assessment, plan) note is a method of documentation used specifically by healthcare providers. SOAP notes are used so staff can write down critical information concerning a patient in a clear, organized, and quick way. SOAP notes, once written, are most commonly found in a patient’s chart or electronic medical records.

To see what a SOAP note template looks like, check out (and use!) this example from Process Street:

 

Click here to get the SOAP Note Template!

How does a SOAP note work?

To illustrate how a SOAP note works, let’s roleplay.

A patient (you) came into a medical practice with arm swelling, but no diagnosis or idea what the issue at hand could be. The physician (me) attended you and I now need to write an initial document that follows the SOAP structure.

First, I’ll be writing the subjective component. Although each component will differ depending on the patient and at which stage the note is being written (numerous notes are written at differing points until the issue is fully rectified), the subjective component often includes information such as:

  • The patient’s age, race, and gender
  • The CC, otherwise known as chief complaint (which, in this case, is the arm swelling)
  • When the chief complaint began
  • Where the chief complaint is located in the body
  • The severity of the chief complaint
  • Description of the chief complaint
  • Relevant medical history
  • And so on.

Once those basics are out the way, I can then move onto the objective component of the SOAP note. Here, I’ll be writing information on what I’ve observed from what you, the patient, are physically displaying and what you’ve verbally told me during our meeting. Plus, I’ll be writing up any findings of any examinations and tests that you’ve had done.

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When writing the objective section, I’ll make to sure write down:

  • Vital signs and measurements, such as blood pressure and weight
  • Findings from physical examinations
  • And the results from laboratory and diagnostic exams.

After that, it’s time to write notes related to assessment. Specifically, I’ll be writing:

  • An analysis of the issue
  • A (potential) diagnosis of the issue
  • And relevant information concerning progress.

Regarding the last point, let’s, for instance, say this is your second visit to the practice regarding the issue but your first visit to me as a physician. I’ll also write a note here regarding how your state has improved or worsened since your last visit.

The fourth and final component is the plan component. It’s here that I’ll create a post-session plan. Every plan written for each patient will be entirely situational depending on who they are, what the issue is, and what stage they’re at, but plans often include:

  • Medication prescriptions
  • Referrals to other medical departments or personnel
  • Additional/extra tests that should be conducted
  • Follow-up appointments
  • And whatever else is deemed necessary.

The next steps, just like the plan itself, will differ. Some medical practices may want the fully-written SOAP note to be reviewed and/or approved by a higher-up, while some practices will want the SOAP note writer to upload the completed document to a database of medical records. Or, the best plan of action may be to carry out the action tasks in the plan as soon as possible.

Either way, by following the SOAP note method of documentation, it helps to order and organize the process of note-taking that’s otherwise prone to countless human errors and mistakes!

The history of the SOAP note

SOAP note history

The SOAP note isn’t some made-up mumbo-jumbo; rather, it has a long history rooted in the need to solve complex real-life problems faced by real-life practicing physicians on a day-to-day basis.

Here’s a short history lesson for you.

As the 1960s ended and the 70s began, Dr. Lawrence Weed stumbled upon a significant problem. As a practicing physician but also an academic researcher and teacher, he realized that not having a standardized process for medical documentation was, well, pretty sub-par.

So that physicians like him could write up notes and the information they contain quickly and in a systemized way, Dr. Weed came up with the POMR – an acronym for the problem-oriented medical record.

As Dr. Weed said himself in a Permanente Journal interview:

“The multiplicity of problems the physician must deal with every day constitutes a principal distinguishing feature between a physician’s activities and those of many other scientists. These realizations led me to develop the POMR so that medical students and practitioners could function in a structured, rigorous way more like that of workers in the scientific community.

The POMR cannot change the multiplicity of problems that physicians face. But the POMR enables a highly organized approach to that complexity.” – Dr. Lawrence WeedInterview with Lawrence Weed, MD: The Father of the Problem-Oriented Medical Record Looks Ahead

The POMR is still used by medical organizations around the globe, and it’s what the SOAP note itself originates from.

Seeing as the SOAP note originates from the POMR, you’d be right in thinking there’s substantial overlap. However, there is variation.

To illustrate this in the simplest possible way, there are 5 main components of the POMR. These, as listed by the Imhotep Virtual Medical School, are:

  1. A database concerning patient history, physical tests, and laboratory exams
  2. A complete problem list
  3. Initial plans
  4. Daily progress notes
  5. And a final progress note or discharge summary.

The SOAP note, however, is different in terms of what’s required of it and the way it’s structured, despite the large overlap.

The POMR and SOAP note way of doing things also came about due to Dr. Weed’s understanding that the medical world needed to adapt to information technology. After all, if information technology can help individuals and teams complete an important process – or a collection of essential processes – more efficiently and effectively, why not harness its power?

As Dr. Weed said himself:

“I realized that medicine must transition from an era where knowledge and information processing capacity resides inside a physician’s head to a new day where information technology would provide knowledge and the processing capacity to apply it to detailed patient data.

The physicians’ unaided minds are incapable of recalling all the necessary knowledge from the literature and processing it with data from the unique patient. An epidemic of errors and waste is occurring as we persist in trying to do the impossible. Changing this requires that we recognize the crucial distinction between electronic.” – Dr. Lawrence WeedInterview with Lawrence Weed, MD: The Father of the Problem-Oriented Medical Record Looks Ahead

With what Dr. Weed said in mind, it’s no surprise that the SOAP note picked up major traction in the 70s, as it turned the impossible into the possible (with a helping hand from IT and tech, of course).

It’s not only physicians who are using SOAP notes in the modern-day, too – it’s also behavioral healthcare practitioners to veterinarians!

The SOAP note, then, is useful for pretty much everyone in the medical field.

The benefits of SOAP notes

 

soap note benefits
(Source)

Now, the SOAP note wouldn’t have survived this long – nor would it be used by practitioners working in different areas – unless it’d brought about some nifty benefits.

Reader, I’m pleased to tell you my prognosis is that the SOAP note does bring multiple benefits across the board.

Specifically, these positives include:

    • Orders and organizes how information is written. ✏️

At its core, the SOAP note is all about ordering and organization. Considering tens of notes could be written by a healthcare provider on any given day, having a systemized way of writing up important notes is integral in itself. Here’s to keeping organized.

    • Quickens the note-taking process. ⚡️

Another core element of the SOAP note is, with a structure for how to write notes, it quickens the note-taking process overall. This is because you’re not jumping to-and-fro after forgetting a certain question, and not having to go back and add to your notes after the fact because you’d forgotten to pen an important detail down.

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