SOAP
SOAP stands for Subjective, Objective, Assessment, and Plan. A SOAP note is a method of documentation used by healthcare providers, particularly in fields like medicine, nursing, and allied health professions, to organise patient information in a systematic format. The acronym "SOAP" stands for:
Subjective: Patient-provided information like complaints, symptoms, and medical history.
Objective: Observable data from tests, measurements, and examinations.
Assessment: Healthcare provider's analysis of the patient's condition, including diagnoses.
Plan: Outline of treatment, including medications, tests, referrals, and follow-up instructions.
SOAP notes ensure comprehensive documentation, aiding communication among healthcare teams and serving as a legal patient care record.
SOAP Example
SOAP example
Patient presenting 3 day history of cough and fever likely viral URTI
Plan - symptomatic management, review 1 week, increase use of Ventolin
History:
Patient presents with a 3-day history of cough and fever.
worsened overnight
starting getting ear pain, runny nose and sore throat
Associated symptoms include shortness of breath and malaise. Denies chest pain or hemoptysis.
No recent travel or known exposure to infectious diseases.
cough is productive
coryzal symptoms present
no red flags - non smoker
PMHx: Asthma, seasonal allergies.
Current medications: Salbutamol inhaler, loratadine.
Social history: Has been in contact with some sick contacts, living at home with partner who smokes
family history of atopy and asthma
uptodate with flu shot but needs covid vaccine
Examination:
Temp: 38.2°C, HR: 88 bpm, BP: 120/80 mmHg.
Examination findings:
heart sounds x 2
Bilateral wheezes on auscultation, no crepitations.
Mild pharyngeal erythema.
ears erythematous both sides
Assessment & Plan:
1. Acute Bronchitis
Likely viral etiology given the acute onset and associated symptoms.
Recommend symptomatic management with increased fluid intake and rest. Consider over-the-counter cough suppressants if necessary.
Follow-up in 1 week if symptoms persist or worsen.
2. Asthma Management
Asthma symptoms may be exacerbated by current upper respiratory infection.
Continue use of salbutamol inhaler as needed. Review inhaler technique and consider increasing dose if no improvement.
Schedule follow-up to reassess asthma control.