SOAP Notes Flashcards
1
Q
What does SOAP stand for?
A
- Subjective
- Objective
- Assessment
- Plan
2
Q
What are the purposes of clinical notes?
A
- Describe how we understand our patient
- Facilitate safe, high-quality care
- Demonstrate our accountability for our practice
3
Q
When do we write clinical notes?
A
- Ideally, at the same time/immediately after the clinical encounter or at least, when the encounter is fresh in our minds
- Record the date and time
- We add to the notes/record a new set of notes when they add value
- If you do not write notes after every interaction, it is important to justify why
- In many in-patient centres or care homes, we write clinical notes only in the cases of “remarkable” interactions
4
Q
What are clear clinical phases notes should reflect on?
A
- Prehabilitation/Peri-operative (where appropriate)
- Initial assessment
- Progress
- Discharge
5
Q
What do we write in clinical notes?
A
- Assessment and findings
- Any investigations: ABG, CxR, blood tests etc
- Physiotherapy specific assessment
- Goals
- Treatment/management plan
- Referrals
- Screening tools
- Questionnaires, outcome measures
6
Q
What are the “4 audiences” for clinical notes?
A
- Clinician writing the notes
- Patient
- MDT
- Third parties (Hospital manager, quality assurance auditors, researchers etc)
7
Q
What is the Subjective section of SOAP notes comprised of?
A
- Chief complaint (CC) or presenting problem
- History of current condition/presenting illness (use acronym OLDCARTS)
~ Onset, Location, Duration, Characterisation, Alleviating and Aggravating factors, Radiation, Time/Temporal patterns, Severity
~ All the patients’ symptoms will be mentioned here - Other components of subjective history
- Review of systems (ROS)
~ General
~ Gastrointestinal
~ MSK - Medication, allergies
8
Q
What is the Objective section of SOAP notes include?
A
- Vitals/obs
- Physical exam findings
- Laboratory data (blood tests, LFTs, PFTs etc)
- Imaging/radiographic investigations
- Other diagnostic data
- Recognition and review of documentation of the other clinicians
9
Q
What is the Assessment section of SOAP notes include?
A
- Differential diagnosis/hypotheses based on objective assessments (more seen in MSK)
- Problem list (must be prioritised)
- Any discussion around the patient, problem list, contraindications, precautions etc
10
Q
What does the Plan section of SOAP notes clearly state?
A
- Treatment/technique details (including load, sets and reps)
- Specialist referrals or consults (eg: requesting clinician support to prescribe O2)
- Patient and carer education, counselling
- Any additional tests and why including next steps if positive or negative (eg: requesting CxR to see if pleural effusion resolved)
- Follow-up plan