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A SOAP note is written by health care providers after examining a patient. The length and focus of each component of a SOAP note varies depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focuse on issues that relate to post-surgical status (e.g., it will often be noted whether the patient has passed gas, because if they have, it is considered by many physicians to be safer to allow them to eat.) The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. An very rough example follows: S: No Chest Pain or Shortness of Breath. "Feeling better today." Patient reports flatus. O: signs, lab data, and physical exam results would be recorded here. A: Patient is a 37 year old man on post-operative day 2 for laparoscopic appendectomy, recently passed flatus. P: Advance diet. Continue to monitor labs. Prepare for discharge home tomorrow morning. |
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