The soap note abbreviated for subjective, objective, assessment and planning cues used by health care professionals when dealing with patient care. The four stepped note works by firstly getting a verbal description by the patient of his present condition, examining physically as taking the blood pressure reading and temperature of the patient, based on physical examination make assessments and then devise an action plan.
Providing the patient with correct medication is the next step and finally analyzing that whether the medication has helped improved the patient’s condition or has worsened it than before.Soap notes are generally prepared by either doctors or nurses.
Understanding the soap note
- Subjective cue: Patients themselves can draw a far better picture of their condition than anyone else can. In this section, your verbal communication with the patient regarding his present condition like how he is feeling etc. is recorded. Mostly the cutest ones are recorded.
- Objective cues: Physical assessment of the patient is recorded here. Physical attributes will include factors like blood pressure, body temperature etc.
- Assessment cues: Here the doctor o the nurse writing the soap note writes down the diagnosis reached based on the information given by the patient.
- Planning cues: After examining the present condition of the patient, in this section, the doctor or nurse provides him/her with remedies to deal with the disease. A patient care list is devised.
The soap note basically gives an idea of the patient’s present condition with the help of which doctor’s propose of what next should be done regarding the present condition. After this, the patient is provided with medication and results are evaluated. In the end, the desired result is compared with the expected result and further analysis is performed.
Clearly written and well-organized patients care detail written by professionals is what a soap note has. Beneficial to use not only today but also available for future references when needed. A clear demonstration of patients present condition and also past when used for the purpose of future recommendations.
soap Note Template