SOAP Notes Flashcards

1
Q

What does SOAP stand for?

A
  • Subjective
  • Objective
  • Assessment
  • Plan
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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
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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
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4
Q

What are clear clinical phases notes should reflect on?

A
  • Prehabilitation/Peri-operative (where appropriate)
  • Initial assessment
  • Progress
  • Discharge
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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
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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)
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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
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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
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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
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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
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