Soap Note Example

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amta soap notes form
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Undergraduate Academic Orientation Packet - MD Anderson Cancer bb - mdanderson
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Soap Note Example

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What is a SOAP Note?

A patient’s chart is created by means of such documentation as a SOAP note template. It is used by health care workers. It includes four parts. Below you can see all of them:

  • Subjective: in this part, the current condition of the patient is described in narrative form. It consists of the chief complaint or probably a reason for coming to a medical worker. There are such points as the onset, chronology, quality, severity, modifying factors, additional symptoms and treatment.
  • Objective: in this part of the SOAP note example, the traceable facts about the status of the client are documented. It includes the vital signs, laboratory results, measurements (age, weight, etc.) and physical examination findings.
  • Assessment: in this part, a medical diagnosis is included.
  • Plan: in this part of the Sample SOAP Note, a health care provider includes their possible actions regarding the patient. It may be referrals, medications prescribed, ordering labs or procedures to be performed.

This is a standard example of a SOAP note. Every medical worker must fill it out to record every step of the patient’s treatment process.

How to Fill Out a Soap Note

Generally, there are two available options. First of all, it is possible to write everything manually, printing out the document and using a pen for filling out all necessary fields.

Secondly, there is the option of downloading a PDF or Word format SOAP Note Template Form and simply typing all the information. You have access to many editing tools, which will greatly simplify the process of writing a soap note. Thus, you avoid all unnecessary paperwork, save time and can pay more attention to your patient.