Monday, 27 January 2014

EMR SOAP Notes

Usually patient Medical record refers to SOAP Notes or patient encounter or Patient visit record. We will see the components of the SOAP Note here.

A SOAP note is a documentation method employed by health care providers to create a patient’s chart.  There are four parts of a SOAP note: ‘Subjective, Objective, Assessment, and Plan.

1. SUBJECTIVE

The initial portion of the SOAP note format consists of subjective observations. These are symptoms the patient verbally expresses or as stated by a significant other. These subjective observations include the patient's descriptions of pain or discomfort, the presence of nausea or dizziness, when the problem first started, and a multitude of other descriptions of dysfunction, discomfort, or illness the patient describes. To put simple, this section to record the reason why the patient came to meet the physician.

The following sections will be covered under the Subjective.

  • Chief Complaints
  • Family History
  • Social History includes Smoking , alcohol and Drug history.
  • Problem List (Current Problems)
  • Past Medical History
  • Past Surgical History
  • Current Medication History
  • Allergy
  • Review of Systems (ROS)
  • Birth History

2. Objective

Documents objective, repeatable, and traceable facts about the patient’s status.These objective observations include symptoms that can actually be measured, seen, heard, touched, felt, or smelled. Included in objective observations are vital signs such as temperature, pulse, respiration, skin color, swelling and the results of diagnostic tests.

The following sections will be covered under the Subjective.

  • Vital Signs and measurements, such as weight, height, etc.
  • Physical Examination
  • Results from Laboratory and other Diagnostic tests already completed.

3. Assessment

A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. It is the patient's progress since the last visit, and overall progress towards the patient's goal from the physician's perspective. When used in a Problem Oriented Medical Record, relevant problem numbers or headings are included as subheadings in the assessment.


4. Plan

This is what the health care provider will do to treat the patient's concerns - such as ordering further labs, radiological work up, referrals given, procedures performed, medications given and education provided. This should address each item of the differential diagnosis. A note of what was discussed or advised with the patient as well as timings for further review or follow-up are generally included.
Often the Assessment and Plan sections are grouped together.

The following sections will be covered under the Subjective.

  • Prescription
  • Order Lab Test
  • Refer to other Doctor
  • Instruction and Plan for the patient
  • Patient Education

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