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In it's strictest definition it is a type of problem oriented charting where you list each patient problem and then SOAP each one. sagarcia210 has broken it down quite simply for you. SOAP is an acronym and indicates the sequence you want to chart these items. A general nursing note or physician's progress note can be written in the SOAP format as well. You start by writing S- and then listing subjective information the patient has told you. Then, O- followed by a listing the objective data you find. A- followed by how you are putting it all together and making an assessment. For nursing that would be a nursing diagnostic statement or simply a statement that the patient's condition continues to improve or decline and then you write a P- and list your plan of action which would generally follow what is on the nursing care plan. You sign your name at the end of all this.
I am a medical assistant and I work in a clinic that charts like this. The medical assistants role in this is to chart the subjective findings, what the patient tells you in the chart. But what I am having a problem doing is do I actually write the exact words of the patient in the chart, or do I reword them and use the proper medical terminology to describe to the doctor what the patient says is wrong with them. Everybody has been complaining that my charting is too wordy and I have not used proper medical terminology, but what I am doing is putting Pt states.... and then I write down everything that they tell me in their words. Thats how I was taught in school to do it.
Subjective data is the patients interpretations on their illness. I always write their words. As far as being too wordy, just pick out the information that is most relevant to their individual ailment.
I am an RN who went through EC to get my ASN. I hear the nursing students at work always talking about getting their SOAP notes done. What are SOAP notes?
I'm not sure what "EC" is, but SOAP Notes have been around for years. I learned how to take notes in SOAP format over 20 years ago when I was a Navy Hospital Corpsman. S - Subjective data - supposed to be "verbatim" what the patient tells you, ex: I fell and hurt my left foot, etc. O - Objective - ex: X-Ray report confirms fracture to left ankle... A- assessment - patient complaints of pain to left ankle, patient is unable to move left ankle, bruising, edema, etc. to L ankle. P - Plan - you decide your plan of care based on the MD Orders - immobilizing the limb, heat, cold packs, elevating the limb, etc.
@giada23 I can see why you are doing what you do when it comes to documenting. I use to be a Medical Assistant Instructor and we did teach that we have to document what the patient states and to do it in their own words. However there is a limit to this. Do you remember the 6 C's of charting?
1.Client words 2. Clarity 3. Completeness 4. Consice 5. Chronological order 6. Confidentiality This is a good technique for keeping for notes short and sweet, but to the point and with the accurate information. Nurses can use this techniques as well. SOAP notes, though, is a documenting format that is used to get the nursing process on the way. This is by finding out the Subjective data (CC), Objective data (measureable data), Assessment (deciding what is wrong with the pt) and Planning (what to do). After this the ADOPIE is put into practice which is Assessment, Diagnosis, Outcome and Planning, Implementation and Evaluation. This is a mouth full. But each individual practice has the same general idea/format for documenting the same thing. For the part where you have to put what the patient says into a note, what nurses do is to paraphrase: write what the patient said, put it into a medical note, using proper medical terminology and anything that stands out as important put into 'pt stated' and then use a "quote". I hope that this helps. Sorry, Im wordy too.
Subjective patient info (What is the patient saying? Pain level?)
Assessment based on subjective and objective info
Implementation (What we actually did)
Evaluation of our plan and implementation
Reassessment of plan if needed.