SOAP Notes

Question 1

What does SOAP stand for?

Answer 1

• Subjective
• Objective
• Assessment
• Plan

Question 2

What are the purposes of clinical notes?

Answer 2

• Describe how we understand our patient
• Facilitate safe, high-quality care
• Demonstrate our accountability for our practice

Question 3

When do we write clinical notes?

Answer 3

• 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

Question 4

What are clear clinical phases notes should reflect on?

Answer 4

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

Question 5

What do we write in clinical notes?

Answer 5

• Assessment and findings
• Any investigations: ABG, CxR, blood tests etc
• Physiotherapy specific assessment
• Goals
• Treatment/management plan
• Referrals
• Screening tools
• Questionnaires, outcome measures

Question 6

What are the “4 audiences” for clinical notes?

Answer 6

• Clinician writing the notes
• Patient
• MDT
• Third parties (Hospital manager, quality assurance auditors, researchers etc)

Question 7

What is the Subjective section of SOAP notes comprised of?

Answer 7

• 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

Question 8

What is the Objective section of SOAP notes include?

Answer 8

• 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

Question 9

What is the Assessment section of SOAP notes include?

Answer 9

• 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

Question 10

What does the Plan section of SOAP notes clearly state?

Answer 10

• 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