Posted: September 7th, 2021
An episodic SOAP note is a document that is used in the treatment process in the health sector. Its main purposes are to inform the clinical practitioner handling the patient and provide evidence that the patient has been clinically examined. It was created by Larry Weed almost five decades ago as part of the Problem-Oriented Medical Record (POMR) to help healthcare workers document their findings in a structured way. A significant number of medical practitioners replaced POMR with SOAP after it was developed.
The words SOAP is an acronym that stands for Subjective, Objective, Assessment, Plan.
This is the patient’s explanation of what the problem is. It is usually in the form of a summarized narration.
The subjective component included a history of the illness from the time of its initial symptoms to the current stage. Additionally, the patient’s medical, surgical, social, and family history is also recorded.
Some of the errors that healthcare practitioners might make at this stage include passing judgment on the patient; for instance, making the conclusion that they are exaggerating their symptoms. It is also important to avoid recording unnecessary information.
The subjective component may also include a description of the patient’s symptoms from a different source such as a family member or caregiver.
The objective component included the information that is collected from the patient’s current health situation. These include; measurements such as height and weight, vital signs, and findings from physical examinations. The healthcare provider should ensure that they provide adequate detail in this section.
This is a summary of the key symptoms and diagnosis of the patient, and a list of other likely diagnoses. The assessment will also describe the patient’s progress since the last visit as well as the most effective therapy options for the patient.
The plan component is the steps that the healthcare provider will take to treat the patient and address their concerns. The plan also includes a description of the objective of the treatment.
One of the main advantages of episodic SOAP documentation is that is a generally accepted documentation practice in healthcare, therefore leading to familiarity, reliability, and comparability.
The episodic SOAP note documentation format also leads to a clear and well-structured record of clinical findings, which shows the progress of events in sequence from the collection of the relevant data, to the evaluation, and finally to the plan on how to proceed.
The episodic SOAP document has been criticized for summarizing excessively, as well as using too many acronyms and abbreviations. The language used is sometimes considered to be too challenging for the layman to comprehend.
SOAP notes do not provide adequate guidance on the best way to address functional outcomes and objectives.
Another disadvantage of a SOAP note is that it does not record the changes that occur over time.
Additionally, there has been concern that the order that the episodic SOAP note follows would be faster if it would be rearranged to APSO.
According to the American Physical Therapy Association, the following information should be included in an episodic SOAP note:
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