IEP, Writing Goals, and SOAP Notes Flashcards
What does SOAP stand for in S.O.A.P. notes?
S = Subjective, O = Objective, A = Assessment, P = Plan
Why are SOAP notes important?
They organize information, communicate clinical issues, facilitate clinical reasoning, and serve as a useful tool for shift changes and future encounters.
What types of personal identifiers should be excluded from S.O.A.P. notes?
- Name
- Birthdate
- SSN
- Phone #
- Address
What types of information are included in the Subjective section of S.O.A.P. notes?
- Health history
- Condition/chief complaint
- Functional status/activity level
- Cultural and religious beliefs
- Living environment
- General health status
- Social/health habits
- Current/past medications
What does the Objective section of S.O.A.P. notes contain?
Observable and factual information obtained during examination
How should information in the Objective section be organized?
- Use headings, caps & underlining
- Use tables or charts
- Use flow sheets
- Be specific
- State affected anatomy
- State information in measurable terms
List some examples of Objective information.
- Vital signs
- Physical exam
- Labs
- Diagnostic tests
- Medications
What type of information is included in the Assessment section of S.O.A.P. notes?
Professional opinion based on Subjective & Objective portions, including diagnosis and further testing needed.
What are the components of the Plan section in S.O.A.P. notes?
- Frequency (per day or per week)
- Interventions
- Location
- Treatment progression
- Plans for discharge
- Patient & family education
- Equipment needs
Fill in the blank: The S.O.A.P. notes are a written record that organizes information from the _______.
[history & physical exam]
True or False: The Objective portion of S.O.A.P. notes includes subjective opinions from the patient.
False
What is the purpose of the Assessment section in S.O.A.P. notes?
To provide a diagnosis and identify any inconsistencies or further testing needed.
What should be included in the Plan section regarding patient education?
Patient & family education
