The SOAP format enhances communication: the SOAP format provides a clear and concise way of documenting patient information.
In the POMR, problems identified on initial contact with the patient are placed in a fist and assigned a number. Subsequent visits are documented by including the previously assigned numbers next to the corresponding SOAP note, or by adding new numbers for new problems and new SOAP notes. The SOAP format is a way of documenting the data collected from patients in a clear, concise and well organised structure.
Over time, other professions began to use this approach, as it was thorough yet concise, pieced data in categories all providers could rapidly identify, and improved communication between professions.
Today, the SOAP format is used around the world by nurses, pharmacists, occupational therapists, dieticians, physical therapists, message therapists, physicians, social workers and psychiatrists. In New Zealand, a wide variety of health care professionals use the SOAP format. It is becoming an increasingly popular strategy for nursing documentation and is being taught at both the graduate and postgraduate levels of education. An informal poll of members of Nursing Educators in the Tertiary Sector revealed that at least four university nursing programmes and two institutes of technology were teaching SOAP documentation to their students; SOAP is used at all DHBs in at least one department; and at least one community nursing agency is using SOAP documentation. (3) Internationally, the SOAP format has been used extensively in computerised patient or medical records.
SOAP is well recognised and its use within the changing focus of health care from the problem to the patient is unlikely to decrease. It can be used to document the complete history and physical examination of a new patient, the episodic visit of a well-known patient to a clinic, the first contact at the beginning of a shift, an emergency visit, or a routine follow-up visit. The amount of data included in the SOAP is determined by the reason for the visit and the type of supplemental paperwork used in the clinical setting.
Subjective data (S): This includes all the things the patient has stated. Items that would be included in this section are: presenting concern; history of the presenting concern; any allergies; if conducting an initial history or complete history, current medications; past medical history; immunisations; family history; social history; and the review of the body systems. If this is an ongoing contact with a patient, eg in a hospital setting, S would be considerably abbreviated, perhaps including only the patient's response to questions Eke: How was your night? or How are you doing this morning?
Objective data (O): These are all the observations made by the health professional during the examination of the patient. Information in this category includes vital signs, general appearance and mental status of the patient, and observations from each system of the body that is examined. Laboratory test results returned during the actual clinic visit or available at the time of documentation can also be included in this section, as the laboratory or x-ray results help to determine the actual and potential diagnoses. As in S, the amount of data included in this section is a reflection of patient need and the clinic setting.
The assessment or analysis (A): This is the list of all actual and potential health problems the health professional has identified, as a result of the data collected. Nothing can be in A that has not been addressed in the S or the O sections. The assessment or analysis must also reflect the scope of practice of the health practitioner. Finally, the A must be complete, as it will dictate the plan. This section is not a repetition of data previously recorded in S and O, rather it is the conclusions reached, based on the data collected in those sections.
The plan (P): It is divided into four sections. The first includes all the medications, devices, or appliances recommended or prescribed for the patient, based on what is included in A. If nothing is being recommended, this section is omitted. The second section is a list of any pending results of ordered diagnostics, or a list of diagnostics the patient is to undergo in the future, or both. The third section--the one that is often overlooked--is the one labelled "patient teaching". Here, all the topics covered with the patient, family or other caregivers are listed. It is important to document what was addressed and what written materials were given to the patient during the contact with the health professional. Finally, section four lists any referrals or consultations to be made, and when and why the client is to follow-up with each health professional.
The SOAP format can be used to document any type of patient encounter by a variety of health professionals. The clear, comprehensive, accurate, yet concise SOAP format, enhances communication between members of the health care team, serves as a reminder of the care planned, documents care provided for the individual, and meets legal and institutional policy requirements for record keeping. Further, the SOAP format and the problem or patient-oriented medical record adapts well to electronic health records.
Finally, the SOAP format, when adhered to by all health care professionals, allows for integration of notes by all professionals into one document and allows all to quickly find needed information about the patient/client, promoting more efficient, comprehensive care.
(1) Weed, L. (1968) Medical records that guide and teach. The New England Journal of Medicine; 278: 11, 593-599,652- 657.
(2) Weed, L. (1969) Medical records, medical education, and patient core: The problem oriented medical record as o basic tool. Cleveland, Ohio: Case Western Reserve Press.
(3) Donnelly, W. (2005) Patient-centered medical care requires a patient-cantered medical, record. Academic Medicine; 80: 2, 33-38.
(4) Email Responses (2008, September) Informal Survey on Nursing Educators in the Tertiary Sector List serve.
Mary Jo Gagan, RN, NP, PhD, is senior lecturer at the Centre for Postgraduate Nursing Studies at the University of Otago, Christchurch.
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|Title Annotation:||PRACTICE; subjective, objective, assessment/analysis, plan|
|Author:||Gagan, Mary Jo|
|Publication:||Kai Tiaki: Nursing New Zealand|
|Date:||Jun 1, 2009|
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