Chart notes are dictated in various formats such as a History and Physical Examination (H&P) report with similar headings and less depth, as a single paragraph with few sentences, or using SOAP format. Most physicians rely on medical transcription services to ensure accurate and timely patient records.
Benefits of the SOAP Format
Created by Dr. Lawrence Weed in the 1960s, SOAP expands to Subjective, Objective, Assessment and Plan and medical transcriptionists transcribe chart notes with these letters as headings. The SOAP note allows healthcare professionals to assess, diagnose, and treat patients. It helps organize information about the patient’s health status and facilitates communication among health professionals. The SOAP format as it can be tailored to any kind of study or study visit. Its structured documentation provides a checklist and a reference for understanding the patient’s record. SOAP notes are used by almost all healthcare professionals, ranging from medical doctors, to dentists, psychologists, nurses, emergency medical technicians and veterinary practitioners.
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Description of the SOAP Note
Here is a detailed description of the SOAP acronym along with an example of a SOAP Note for a substance use case:
- Subjective – The Subjective section of the SOAP note is where healthcare providers document the subjective information provided by the patient or their caregiver. This section focuses on the patient’s personal account of their symptoms, medical history, and other relevant subjective information that cannot be directly observed or measured. Medical history focuses on any current or past conditions The Chief Complaint (CC) or presenting problem is reported by the patient. This can be a symptom, condition, previous diagnosis or another short statement that describes why the patient is presenting on the day. This section describes how the patient has been doing since the last visit and also includes the current visit. It may include no complaints (I feel good) from the patient and specific current complaints (I have low back pain) as well as the complaints (I had diarrhea a few weeks ago) that occurred in the interim and have been resolved. S: Mr. X has been well since last visit and reports no complaints today. He states that he has not used any drugs since the last visit including IV drugs. Current medications and allergies may be included under the Subjective or Objective sections.
- Objective – The objective section includes vital signs such as temperature, blood pressure, pulse and respiration, documentation of the physical examination performed, results of laboratory or other studies done during the visit. This section may include a sentence or two about the relevant body part or refer to another document or stuffed with jargon, abbreviations and acronyms to make the documentation as small as possible, which the behavioral medicine transcription service provider should document exactly as dictated. Previous reports may have to be referred to in order to understand the terms. .O: T: 37 C (by mouth); BP: 130/68; P: 70; R: 14.
Exam of arms: well healed linear scars along the antecubital area. - Assessment – This section refers to short assessment of the patient by the clinician based on the subjective information and objective findings gathered earlier. A: 40-year old man enrolled in HPTN XYZ. No evidence of current IV drug use.
- Plan – The Plan section of the SOAP note is where healthcare providers outline the course of action for the patient’s care. It includes the recommended treatment plan, management strategies, and any follow-up actions. The Plan section is based on the assessment and diagnosis made in the previous sections of the SOAP note, namely the Subjective, Objective, and Assessment sections. P: Continue with counseling sessions. Client is scheduled to return for Visit 7 on November 12. Client is also reminded to contact or return to clinic if there are any problems before that date.
The assessment and Plan section can be separated or combined (A/P). It is not necessary to number multiple diagnoses unless specifically requested. Also, the transcriptionist does not need to expand diagnoses acronyms in SOAP notes as in other reports. Some dictators may use different sets of abbreviations to refer the same thing such as:
- CC: Acronym for chief complaint, equivalent to subjective
- PX or PE: Shorthand for physical examination, equivalent to objective
- DX: Abbreviation for diagnosis, equivalent to assessment
- RX: Abbreviation for prescription, in this case prescribed treatment plan
Sometimes, a physician/nurse may leave certain sections or mix and match headings (for example, the Chief Complaint may be dictated in place of or in addition to Subjective). Headings dictated should be transcribed unless there is a specific instruction to do otherwise.
It is also important to note that there may be certain differences in the information added in SOAP notes in different clinical settings. For example, the Lachman test, a special orthopedic test for ACL injury, may be added to the Objective section by the physical therapist or orthopedic doctor, but not by a nurse.
Outsource Medical Transcription — Ensure Documentation Accuracy
Medical documentation has evolved over the years to meet various needs, leading to longer and more comprehensive medical notes compared to the past. With the shift towards electronic documentation, medical notes have transitioned into digital formats to accommodate these changing requirements. However, note bloat is an unintended consequence of electronic documentation, leading to overwhelming amounts of data to be incorporated into the notes. This can burden busy clinicians and pose risks if the information is not relevant or accurate, potentially leading to harm for the patient. Partnering with a competent medical transcription company can ease the documentation burden for physicians, ensure clinical note accuracy, and allow physicians to focus on patient care.
