Soap Notes Flashcards
1
Q
what does SOAP stand for
A
Subjective
Objective
Assessment
Plan
2
Q
what info should be written in subjective information
A
- consent
- may include HPC, SH and PMH
- patient self report
- info from family/ carer
- patient goals
- handover/ medical info
3
Q
what info should be included in objective information of notes
A
- observations and objective findings
- outcome measures used
- treatmnet/ intervention (be factual)
- any changed in consent
- discussions or advice given to patient/ family
- equipment used/ issued
4
Q
what info should be included in assessment part of notes
A
- analysis of what happened
- import part of legal notes
- professional opinion of findings
- explains your clinical reasoning behind decision making and problem solving
- adverse or positive responses
5
Q
what info should be included in plan part of your notes
A
- specific treament plan
- onwards referral
- discharge plans
- reccomendations to MDT
- if PT compplete or ongoing
