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Q&A for How to Write a Soap Note
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QuestionWhat is the O in SOAP notes?This answer was written by one of our trained team of researchers who validated it for accuracy and comprehensiveness.wikiHow Staff EditorStaff AnswerThe O can stand for either “objective” or “observations.” This section of the note covers objective data that you observe during the examination or evaluation of the patient (e.g., their vital signs, laboratory results, or measurable information like their range of motion during an exam).
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QuestionHow do you write a good SOAP note?This answer was written by one of our trained team of researchers who validated it for accuracy and comprehensiveness.wikiHow Staff EditorStaff AnswerA good SOAP note should be concise, professional in tone, and specific. Avoid anything that sounds judgmental or overly positive or negative toward the patient. Review the language to make sure it’s clear (e.g., check your pronouns to make sure they aren’t confusing and it’s clear who/what you’re referring to).
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QuestionWho uses SOAP notes?This answer was written by one of our trained team of researchers who validated it for accuracy and comprehensiveness.wikiHow Staff EditorStaff AnswerA variety of healthcare professionals use SOAP notes to help them assess their patients. This can include doctors, counselors, physical therapists, and emergency medical technicians. SOAP notes are especially helpful for sharing information between different providers who are treating the same patient.
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QuestionHow do you do soap notes on hypothermia?Community AnswerSubjective: Whatever the patient is telling you: "I feel cold," "my hands are numb," etc. Objective: Whatever you observe: Patient is shivering, lips are blue etc. Assessment: General Observation. Plan: Your Tx: warm fluids, remove wet clothing etc.
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QuestionWhat are the parts of the SOAP information that is not recorded?Community AnswerEverything should be recorded for your benefit and your clients. If they should see someone else later on, that person treating them needs to know all the details.
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QuestionWhat is active range of motions?Community AnswerAny motions that patients do themselves. Passive would be you doing it for them.
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