Sample Note

All About Writing Notes & Sample Notices

SOAP Note

Soap Note is a short form of the Subjective Objective Assessment Plan Note that is usually written by professional medical or health care staff. The purpose of writing a Soap note is to make a health issue of a particular patient understandable for everyone and is to make a comparison of the progress of the patient on each passing day. Writing
Soap Notes are a standard way of recording the information about a patient that help the medical staff in proper assessment of the patient as well as help in making decisions regarding the health of the patient. Soap notes are found very helpful in medical emergencies as doctors have the complete data of a patient and the speed and manner of recovery from a certain health issue.

A Soap note is based on four parts consist of some important and relative information.

Subjective Data: It is the first section of a Soap note that is based on a brief history and feelings of the patient and is usually written after conducting a small interview with the patient. Such information includes age and gender of the patient along with the information about the type of health issue like fever, injury or any other issue. Information that is provided by patient is also part of this section.

Objective: This is the second part or section of a Soap note and is based on personal observations like shivering, vital signs, wounds etc.

Assessment: The third part of the soap note is based on the experience of the doctor or nurse in which they try to find what’s actually wrong is with the patient. E.g, hypothermia, anxiety etc.

Plan: It is the final part of a Soap note that is based on the things that a doctor or nurse is going to do, like medicines prescribed, physical or mental therapies etc.

A Sample Soap Note

                                                                             Soap Note  
    Date:                                                                                                          Time:
                                                                PATIENT INFORMATION
Name:                                                                                                                                               GENDERAge:                                                                                                                                                      M/FAddress:Phone:                                                                       Notify:

Relation:                                                                    Phone:

                                                                           SUBJECTIVE
                                                                           OBJECTIVE
 
                                                                           ASSESSMENT
                                                                                 PLAN
 

 

Guidelines for writing a soap Note

  • Always try to use a standard printed format for writing a Soap Note. Usually in hospitals and clinics such notes are available.
  • Write the date and time on the top of the paper where usually spaces are specified in writing date and time. If there is no space specified in writing date and time, it is the responsibility of the medical professional to write the date and time on their own.
  • List the information of the patient like full name, age, gender, address, phone number etc. Ask the patient to provide you a number of his/her relative too.
  • In the subjective section of the note, list a brief history of the patient like for which reason he/she is admitted at the hospital. Ask your patient a few questions like how he/she is feeling and list information with reference to the answers of the patient.
  • In Objective section, list information on the basis of your observations. Check for the vital signs, wound condition etc.
  • List the diagnosis of the patient’s current condition in the category of assessment.
  • Finally, write your prescriptions and thoughts in the section of plan that you think can help in the recovery of the patient.

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