including history taking, documentation...

SOAP Documentation

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It can be a daunting prospect; the thought of writing in medical notes as a nurse practitioner and medically trained colleagues scrutinising your documentation skills. To aid in documentation writing, a SOAP approach can be utilised.  SOAP is a method of documentation initially developed for physicians in the 1960's by Dr Lawrence Weed at the University of Vermont. However, it is a vital documentation writing tool for all healthcare providers today.

Using SOAP documentation provides a methodical approach to writing clinical notes. They enable the practitioner to produce written evidence of patient contact and outline their clinical decision-making process.

The four elements of SOAP are:

  1. Subjective
  2. Objective
  3. Assessment
  4. Plan

Each element of the SOAP is elaborated further in the specific order of the acronym.
Subjective relates to the information provided to the practitioner by the patient and should include:

  • the patients presenting complaint (PC) in their own words
  • the patient's history of presenting complaint (HPC)
  • can use SOCRATES or OLD CARTS
  • include tests, referrals, treatments and outcomes
  • past medical and surgical history
  • can use the mnemonic JAM THREADS
  • previous operations or procedures
  • previous anaesthetics and treatments
  • vaccination history
  • family medical history
  • social history
  • smoking
  • alcohol
  • drugs
  • diet and exercise
  • occupational history
  • travel history
  • sexual history
  • review body systems
Objective relates to the information from observations, examination and test results such as:
  • vital signs and measurements including height and weight
  • examination findings
  • laboratory test results
  • radiology results
  • medication lists from pharmacy, GP or medical records
Assessment includes advice for lifestyle changes, your diagnosis and differential diagnosis.
Plan is where you include your plan of treatment including:
  • operation/procedure
  • medication
  • further tests
  • education
  • follow-up.

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