Templates that enhance your SOAP Note
SOAP is something that you’re probably very familiar with if you’re in the medical field, but are you familiar with SOAP notes? This concept may be one that’s entirely foreign to you, or one that you were taught in medical school.
Whatever the case, SOAP note templates are a useful tool. So what are SOAP notes, and why should you be using a template?
What Are SOAP Notes?
First, for those that are unfamiliar with the concept, what are SOAP notes? SOAP stands for the four note criteria that should be included in your notes:
The subjective section should include information about how the patient feels they’re doing, or how you think they’re doing. Subjective data is based on feeling and emotion, so while it can be useful for patient assessment, you should also include your patient’s medical history.
Objective notes should consist of things like vital statistics, exam results, and observations made of the patient. This information makes up the scientific assessment of the patient.
The A in SOAP stands for assessment, which contains the provider’s judgement of any conditions based on the findings in the subjective and objective areas.
Finally, the P stands for a plan. The plan is where you take everything you find in your notes and turn it all into a functional plan for the care of the patient in question.
This explanation all seems pretty straightforward, so why should you still be using templates to write your SOAP notes?
For practices that are on paper, EHRs that provide digital SOAP notes can have a major impact on practice efficiency including:
Chances are, if you’ve got nurses on your team who use SOAP notes, each one has their own format for their note-taking.
This diversity can lead to confusion among your team members, which can be dangerous for your patients. Templates take away all the guesswork, and each note in a patient’s file is kept to a standard format.
CareCloud’s SOAP notes are designed to help you save time by loosely outlining the questions you need to ask to form a cohesive plan for your patient. The default encounter note within CareCloud Charts is a SOAP note to help our providers quickly document their patient visits.
If the standard operating procedure in your facility is to write up a SOAP note for each patient at the beginning of your shift, without templates, you’ve got dozens of different records in a file with no rhyme or reason to them.
SOAP note templates ensure that patient documentation is consistent regardless of who is on shift, which can also ensure that any significant changes in the patient’s condition are correctly documented and not overlooked.
Example of a Paper SOAP Note Template
For practices that are no longer on paper, there are also benefits when applying templates that can enhance your SOAP note.
Digital models for SOAP notes could include everything from natural fill-in-the-blank fields to shortcuts that allow you to input data with just a few clicks. This setup reduces the amount of time people spend entering data and can also reduce the chance of input error.
SOAP notes can be an invaluable tool. Using this in combination with a template can help save time, streamline input of information, and standardize documentation.
Consider enhancing your SOAP note with a template for a week or two to see how it impacts your patient care and find out how your team feels about it. You might be surprised by the results.
Example of a Digital SOAP Note Template