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Linda Collins Blogger

S.O.A.P. Notes

Posted by Linda Collins | October 16, 2015

​A standardized format for clinical notes is one way to prepare your practice for claims reviews or audits. The most common form of clinical notes is the SOAP note. "SOAP" stands for Subjective, Objective, Assessment and Plan. The SOAP note is a written notation of a patient's condition, progress and immediate plan for diagnosis and treatment. A well-written SOAP note is important for maintaining quality of medical care and for supporting the claim of medical necessity.

S= subjective state of the patient

You have to document the patient's chief complaint and the reason they are seeking medical care. If you haven't done it before, obtain and record a history of the patient's illness including their medical history, past surgery, family history, current medications, allergies and activities of daily living. Document this information specifically – notes that say "performs all normal ADL's" are of virtually no value when you're being audited. Similarly, talk in detail about any pain or loss of function that the patient is experiencing.

Example: The Wrong Way

Mr. Jones has right knee pain. Unable to perform ADL's.

Example: The Right Way

Mr Jones states he is experiencing pain in his right knee. He reports the pain started one month ago after he fell while hiking. Mr Jones is taking OTC pain medication twice a day with no relief. He has been off work the last two days due to increased pain and has had to dramatically curtail even basic activities of daily living (e.g., walking to/from his house/car, taking garbage to the curb, shopping for food, etc.)

O= objective state of the patient

The objective state includes precisely measured patient vital signs, as appropriate – age, height, weight – findings of physical exams and the results of functional tests.

Example: The patient is a 52 year old male who is 5'9" and 193 lbs. He entered the office with the assistance of crutches. Upon examination, the patient's right knee is swollen and tender to the touch. The patient is not able to bend the knee.

A= assessment of the patient, a one- or two-line summary of the patient's treatment

Example: Right knee pain due to OA. Patient measured and fitted with an Unloader Knee brace.

P= plan for the patient

This includes plans for imaging, surgical or non-surgical procedures and medication. Note any referrals to other doctors or specialists and any discussion with the patient. Set times for follow-up and specific goals.

Example: Patient instructed to continue OTC pain medication and to wear the brace during all activities. Follow up with orthopedic physician in two weeks.

All clinical notes are to be dated and signed by the practitioner.

The SOAP note is a well-recognized method of documentation employed by health care providers to write out notes in a patient's chart. Clean up your charts and prepare yourself for audits with SOAP.

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