Writing SOAP Notes

What does SOAP stand for?

SUBJECTIVE History

Items they tell you about the injury or illness

OBJECTIVE Physical Findings

Everything you SEE and DO Results of limitations,

instability, apprehension– General appearance

(discoloration, deformity, rigidity)

– Edema (swelling)– Temperature– ROM– Gait analysis– Method of transport to you– Muscle strength– Muscle tone

– Endurance– Posture– Sensation– Mental alertness– Respiration– Pulse– Skin/wounds– Stress tests (reflexes,

specific tests for body parts)– Functional tests

ASSESSMENT

Educated guess of what it is– The exact injury/illness may not be known

Possible 2° L anterior talofibular ligament sprain

– Suspected site and anatomical structures– 1°, 2°, 3°– Strain, sprain, fracture, etc.

PLAN What to do next

Treatment the patient will receive– First aid treatment, splint, wrap, crutches, re-evaluate

tomorrow a.m.

How do you write SOAP notes?

The written record organizes the info from the history & physical exam.

It must clearly communicate the patient’s clinical issues to all members of the health care team.

It should facilitate clinical reasoning & communicate the patient’s clinical issues to all members of the health care team.

Write it as soon as possible before it fades from your memory– May have to take notes at first until you gain

experience

Date, Chief Complaint, Present Illness, etc.