SOAP Notes

Introduction

SOAP notes are a highly structured format for documenting the progress of a patient
during treatment and is only one of many possible formats that could be used by a health

professional. They are entered in the patients medical record by healthcare

professionals to communicate information to other providers of care, to provide evidence

of patient contact and to inform the Clinical Reasoning process.

SOAP is an acronym for:

Subjective - What the patient says about the problem /intervention.

Objective - The therapists objective observations and treatment interventions (e.g.

ROM, Outcome Measures)

Assessment - The therapists analysis of the various components of the assessment.
Plan- How the treatment will be developed to the reach the goals or objectives

History

SOAP notes were developed by Dr. Lawrence Weed in the 1960's at the University of
Vermont as part of the Problem-orientated medical record (POMR). Each SOAP note
would be associated with one of the problems identified by the primary physician, and so
formed only one part of the documentation process. However, various disciplines began
using only the "SOAP" aspect of the format, the "POMR" was not as widely adopted and

the two are no longer related2

Advantages and Disadvantages

Quinn and Gordon (20o3) suggest that the major advantage of the SOAP documentation
format is its widespread adoption, leading to general familiarity with the concept within
the field of healthcare. It also emphasizes clear and well-organized documentation of
findings with a natural progression from the collection of relevant information to the
assessment to the plan on how to proceed.

However, the format has also been accused of encouraging documentation that is too
concise, overuse of abbreviations and acronyms, and that it is sometimes difficult for
non-professionals to decipher. Delitto and Snyder-Mackler (1995) have also suggested
that a sequential, rather than an integrative approach to clinical reasoning is encouraged,
as there is a tendency by the health professional to merely collect information and not
assess itl3l, They feel that the emphasis on the problem-orientated approach to
documentation is misplaced and that it is not conducive to clinical decision-making.

One major difficulty with SOAP notes for physiotherapists is the lack of guidance on how
to address functional outcomes or goals. Having said that, the format is not so rigid that
it cannot be adapted to take this into account.

Writing a SOAP Note

While documentation is a fundamental component of patient care, it is often a neglected

one, with therapists reverting to non-specific, overly brief descriptions that are vague to
the point of being meaningless. There is no policy that dictates the length and detail of
each entry, only that it is dependent on the nature of each specific encounter and that it
should contain all the relevant information. However, the American Physical Therapy
Association does provide the following guidance on what information should be
includedl:

Self-report of the patient

Details of the specific intervention provided
Equipment used

Changes in patient status

Complications or adverse reactions

Factors that change the intervention

Progression towards stated goals
Communication with other providers of care, the patient and their family
Bear in mind that your report will be read at some point by another health professional,
either during the current inter vention, or in several years time. Therefore, it is your
professional responsibility to make sure that it is well-written.l4
Components of a SOAP Note

Subjective

This component is ina detailed, narrative format and describes the patient's self-report

of their current status in terms of their current condition/complaint, function, activity

level, disability, symptoms, social history, family history, employment status, and

environmental history. It may also include information from the family or caregivers
and if exact phrasing is used, should be enclosed in quotation marks. The patient's goals

and prior response to treatment intervention are also included. Medical information

obtained from the patient's chart can also be included the therapist has not directly
observed these findings. 5

It allows the therapist to document the patient's perception of their condition as it relates
to their progress in rehabilitation, functional performance, or quality of life.

Common errors:

Passing judgment on a patient e.g. "Patient is over-reacting again".

Documenting irrelevant information e.g. patient complaining about previous

therapist.

Objectivee

This section outlines what the therapist observes, tests, and measures. Objective

information must be stated in measurable terms. Using measurable terms helps in

reassessment after treatment to analyze the progression of the patient and hindering as
well as helping factors. I5

The objective results of the re-assessment help to determine the progress towards

functional goals, and the effect of treatment. The therapist should indicate changes in the
patient's status, as well as communication with colleagues, family, or carers.

Common errors:

Scant detail is provided.

Global summary of an intervention e.g. "ROM exercises given".

Assessment

This is potentially the most important legal note because this is the therapist's
professional opinion in light of the subjective and objective findings. It should explain the

reasoning behind the decisions taken and clarify and support the analytical thinking
behind the problem-solving process. A prioritized problems list is generated with
impairments linked to functional limitations. International Classification of Functioning,

Disability, and Health (ICF) is very useful to determine and prioritized problem lists and

thus helps to make functional physiotherapy diagnoses,5

Progress towards the stated goals is indicated, as well as any factors affecting it that may
require modification of the frequency, duration or intervention itself. Adverse, as well as

positive response, should be documented in re-assessment.

Common errors:

The assessment is too vague e.g. "Patient is improving".

Little insight is provided.

Plan

The final component of the note includes anticipated goals and expected outcomes and
outlines the planned interventions to be used. Information should be provided

concerning the frequency, specific interventions, treatment progression, equipment

required and how it will be used, and education strategies. The plan also documents

referrals to other professionals and recommendation s for future interventions or follow

up care.S The therapist should report on what the patient's home exercise programme
(HEP) will consist of, as well as the steps to take in order to reach the functional goals.
Changes to the intervention strategy are documented in this section.

Common errors:

The upcoming plan is not indicated.

Vague description of the plan e.g. "Continue treatment".

Example of a SOAP Note

Current condition: COPD/pneumonia

Goals 1. Pt. will demonstrate productive cough in seated position, 3/4 trials. 2. Pt. will
ambulate 15oft with supervision, no assistive device, on level indoor surfaces.

S: Pt. reports not feeling well today, "I'm very tired".

O: Auscultation findings: scattered rhonchi all lung fields. Chest PT was performed in
sitting lant. and post.). Techniques included percussion, vibration, and shaking. Pt.
performed a weak combined abdominal and upper costal cough that was non-
bronchospastic, congested, and non-productive. The cough/huff was performed with VC.
Pectoral stretch/thoracic cage mobilizations performed in seated position. Pt. given towel
roll placed in back of seat to open up ant. chest wall. Strengthening exercises in standing
pt. performed hip flexion, extension, and abduction; knee flexion 10 reps x 1 set B. Pt.

performs HEP with supervision (in evenings with wife). Pt. instructed to hold tissue over
trach when speaking to prevent infection and explained importance of drinking enough

water.

A: Pt. continues to present with congestion and limitations in coughing productivity. Pt.
has been compliant with evening exercise program, which has results in increased tol to
therapeutic exercise regime and an increase in LE strength. Amb. not attempted to 2° to

pt. report of fatigue. Pt. should be able to tolerate short distance ambulation within the

next few days.

P: Cont. current exercise plan including CPT; emphasize productive coughing

techniques; increase strengthening exercises reps to 15; attempt amb. again tomorrow.