Healthcare professionals have to deal with the issue of physician burnout. They have a challenging responsibility to see and treat patients every day and also complete operational tasks including charting and taking lengthy patient notes from each encounter. It is quite a complex and time-consuming undertaking as all medical records need to be documented precisely and in the right way.
What are SOAP Notes?
The acronym SOAP stands for Subjective, Objective, Assessment, and Plan. SOAP notes facilitate healthcare providers by helping them track the patient’s progress by maintaining initial patient evaluations, diagnoses, and treatment facts in a standardized format. These SOAP notes can also be shared with other clinicians to enhance care coordination and the patient care process. SOAP notes provide an easy way for providers to track a patient’s medical records. When the patient records are organized in a well-defined template the chances of miscommunication and human errors are reduced.
Categories of SOAP Notes
There are 4 components of SOAP Notes which include;
- Subjective – Subjective is what the patients have to say about their health-related issues.
- Objective – This is the complete record of the physical examination of different patient conditions. These include observations such as pulse rate, BP, and temperature.
- Assessment – The assessment comprises a summary of the patient’s diagnosis. For different patient conditions, there might be more than a single diagnosis probability that can be included in the assessment.
- Plan – The final component of the SOAP Notes is the treatment plan which will be followed by the practitioner. This includes medication, surgeries, or therapies to treat a patient’s condition.
Data that needs to be included in SOAP Notes
A well-written SOAP note has the following information in it,
- The patient’s report.
- Medical intervention details.
- The equipment involved.
- Any changes in the patient’s condition.
- Complications that may have occurred.
- If the desired objective has been achieved.
- Details of communication with other providers or family members during the care process.
Key Benefits of SOAP Notes for Medical Professionals
- SOAP notes facilitate the efficient and prompt location of a patient’s complete information.
- SOAP notes are robust enough to help formulate strategies to meet desired treatment goals.
- Through the help of SOAP notes, doctors are well aware of the patient’s health conditions and therefore in a better position to provide an effective diagnosis for improved patient outcomes.
- Helps to reduce physician burnout
EMR Software with SOAP Notes
Some powerful Electronic Medical Records (EMR) software solutions offer the functionality of built-in SOAP notes templates. With the SOAP notes feature the patient records that providers enter are automatically saved on the software system. SOAP notes are so widely used among physicians that using an EHR equipped with SOAP note template creation is unquestionable. The inclusion of SOAP notes in the electronic health records system has many benefits for practice including,
- Double data entry is eliminated which enhances efficiency levels.
- SOAP notes can reduce medical records errors and communication failures, improving patient safety.
- The charting process is simplified and clinicians can better organize patient information.
- SOAP notes provide a way for practices to communicate with each other.
