What's the difference between a progress report and a SOAP note?Register Today!
- by sorchgorch Jun 23, '09What is the difference between a progress report and a SOAP note? Are these two separate documents that are required at different stages of the health care process? Or, is SOAP a way to organize the information found in a progress report. I don't quite get it. I know what SOAP stands for; I just need to know how it is different from a progress report. Thanks so much!
- Jun 23, '09 by Baloney AmputationI'm a medical transcriptionist, and I find that SOAP notes tend to be more of a format for clinic visits. These can be initial visits or followup visits. I find that a progress note tends to be more in the hospital when someone has already been worked up and is being followed periodically by a physician that has already worked up the patient.
- Jun 23, '09 by HouTxSOAP is a structured format for progress notes. S= Subjective, O=Objective, A=Assessment & P=Plan
There is also a "SOAPIE" format - with I= Intervention & E=Evaluation.
The advantage of these formats - it ensures that people actually include meaningful information (data) rather than simply the usual "patient appears to be resting" type notes.
Another structured form is ADPIE: A=Assessment, D=diagnosis, P=Plan, I=Intervention, E=Evaluation
- Jun 23, '09 by MedSurgeMesssome drs in hospital where I'm at use the SOAPIE format, generally all from the same med school, so perhaps it's something that they use as habit, and usually they will add some regular progress note comments at the end. I think that it's just a formatting tool for the practitioner making the note. IMO SOAPIE is nice way to lay out the information to make sure everything is addressed.
- Jun 23, '09 by sorchgorchQuote from lpnfloridaHi lpnflorida!Progress notes are used in most hospitals, Nurses as a rule do not document in the progress notes unless they are advanced practice working in tandem with a doctor.
Thanks for the feedback; this question has been bothering me for a while now. You mention that nurses don't document in the SOAP note unless they are working with a doctor. This confuses me as all the nursing documentation books that I've been reading always include sections on SOAP, PIE, DAR, etc. If the nurse isn't usually involved with SOAP why do they always make sure to include it in nursing books?
By the way, I'm not a nurse!! I'm currently working on a project where I have to write about nursing documentation. It's very difficult when you have no experience as a nurse.
- Jun 23, '09 by caliotter3lpnflorida was referring to a progress note, not a soapie note. Soapie is a format that nurses use for narrative charting. As previously stated, a progress note is used by physicians or advanced practice nurses to chart on a hospitalized patient. Nurses typically write narrative notes that may use the Soapie format. Doctors write progress notes.
- Jun 23, '09 by sorchgorchThanks for the clarification caliotter! In my project I have defined SOAP as a structured progress note, in contrast to the traditional narrative progress note which did not have a formal structure I guess what still confuses me is what is the difference between "narrative charting" and the progress note is in terms of content, if any, or when they are written. Both SOAP and progress notes seem to have the same function, at least to someone outside the nursing field..
- Jun 23, '09 by zahryiaQuote from sorchgorchYes, please to explain.Thanks for the clarification caliotter! In my project I have defined SOAP as a structured progress note, in contrast to the traditional narrative progress note which did not have a formal structure I guess what still confuses me is what is the difference between "narrative charting" and the progress note is in terms of content, if any, or when they are written. Both SOAP and progress notes seem to have the same function, at least to someone outside the nursing field..
- Jun 23, '09 by sailladyThis is my experience. Documentation has changed over the years and is different in various locales. Early on there were Progress Notes for physicians and Nurses Notes for nurses. When I started nursing, we documented our narrative in the Nurses Notes. Physicians used the Progress Notes and used SOAP/IE format. Nurses charted SOAP notes in the Progress Notes when there was a very specific problem. I'm very partial to SOAP/IE notes.
A SOAP note might look something like this.
S: "My left knee hurts today."
O: Left knee, swollen, tender to touch... Walked around the unit for 30 minutes with steady gait this morning.
A: Your assessment
P: Your plan.
Later you would come back and document the evaluation. I'm guessing that SOAP/IE notes would be good for documenting nursing diagnoses, but today institutions may be other ways to do that.
On the other hand, a narrative is a chronological detailing of assessments and patient events, including the mundane ones. Lets say your shift starts at 0700. You may begin by documenting a head to toe assessment. Your narrative charting may resemble something like this.
Neuro: Mental status, neuro check, etc.
Cardiac: EKG rhythm, heart sounds, skin color and warmth, pulses, etc.
Respiratory: Lung sounds, breathing patterns, etc.
You would document the subjective findings in the corresponding system section.
At 0830, you patient may be finished with breakfast. You would document what/how much the patient ate and how well it was tolerated.
Then a family member might visit at 0930 and you would document that and how well the patient tolerated it.
Some hospitals eliminated Nurses Notes and so nurses documented their narrative in the Progress Notes. I remember some physicians were not happy about that. Traditional narrative gives many nurses a sense of security - and I do remember one nurse who swore it was her narrative documentation that saved her during a law suit.
Now nurses also utilize checklists, flowsheets, pathways, charting by exception and electronic medical records. Many nurses still do the narrative in addition to the other required documentation tools. Hope this helps. Others may have a different take on this.