1. { Writing SOAP Notes Ms. Bowman

2.  A documentation method used by health care providers  4 parts  Subjective  Objective  Assessment  Plan What is a SOAP Note?

3.  Describes the patient’s current condition  Usually includes chief complaint  Includes:  Onset  Chronology-what makes it better worse  Quality –sharp, dull, achy, etc.  Severity-pain rating  Modifying factors-what aggravates/reduces complaint-activities, postures, drugs  Additional symptoms  Treatment  Typically reported by patient Subjective

4.  Documents objective, repeatable, and traceable facts about the patient’s statues  Includes:  Vital signs  Findings from physical examinations-posture, bruising, abnormalities  Results from labs  Measurements  Typically observed by clinician Objective

5.  Specific medical diagnosis Assessment

6.  Describes what the health care provider will do to treat the patient  Includes:  Lab work order  Therapeutic modalities  Rehabilitation  Surgery  Medications Plan

7.  Documentation is crucial for health care workers  Provides health care worker of a record of injury/treatment  Provides supporting documents in legal situations  Inter-provider communication  Public health research  Longitudinal patient records  Billing/insurance/reimbursement  “If you didn’t document it, it didn’t happen”  SOAP note format was developed in the 1970s  It gave health care workers rigor, structure, and a way to communicate effectively with each other Why Do You Need to Document?

8.  Must be accurate, clear, and reflect specific services and events  Use appropriate medical abbreviations  Thorough, but not excessively wordy Key Aspects of Documentation