A SOAP note is a form of documentation used by healthcare professionals. The acronym SOAP comes from the four main components of the note: Subjective, Objective, Assessment, and Plan.
SOAP notes were developed by Dr. Lawrence Weed at the Univeristy of Vermont in the late 1960s and are now used in nearly all healthcare professions. Thanks to their wide acceptance in various fields, SOAP notes are used to communicate patient information between professionals across disciplines.
Most electronic healthcare record (EHR) systems feature SOAP note functionality and guide the provider when entering information for all four components.
What Are the Components of a SOAP Note?
There is no standard format for writing a SOAP note. Some providers will write long-form narrative notes, while others will use a list-based style. Regardless of the format chosen, all SOAP notes are broken up into the standard four components:
The Subjective component features a description of the patient’s complaints and their history with the reported illness.
The Objective component is a summary of the provider’s observations during the patient interaction.
The Assessment covers the provider’s diagnosis.
The Plan is the recommended course of action for each of the patient’s problems, ordered by acuity.
Common SOAP Note Abbreviations
Despite the lack of a standardized SOAP note format, there are some abbreviations widely used throughout the healthcare industry. Sometimes providers use the following components of a SOAP note:
RVF: Reason for Visit
CC: Chief complaint
HPI: History of Present Illness
ROS: Review of Systems
PE: Physical exam
Dx: Diagnosis (ICD10)
Rx: Treatment or prescription
How TempDev Can Help With SOAP Notes
TempDev's team of NextGen consultants, developers, and trainers support your needs whether you're looking to implement, switch, or even upgrade your current EHR system. From dashboards and revenue cycle consulting to automation and workflow redesign, TempDev offers the tools you need to make the most of your NextGen EHR system, with top tips and tricks that will ensure your success now and in the future.
With TempDev's NextGen dashboards, templates, and reports, you can better support your patients' needs. Our team is here to help you design, organize, and implement the whole system and is on hand to offer tips and guidance based on industry best practices.
Contact us here or by calling us at 888.TEMP.DEV to get the help you need to work with SOAP notes.
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