Documentation has many purposes, from assuring quality care to communication to discharge planning. It has become very important in a Health Care atmosphere that includes lawsuits and the need of third-party payers to obtain clear and accurate information.

The SOAP note is one of the more commonly used forms of note writing.

The SOAP format lends itself well to writing an initial note, as well as to writing interim notes and a discharge summary for each patient seen in therapy.

It is probably the most comprehensive form of document encountered by most practitioners.

The SOAP method of writing notes serves as a guide to thinking through problems, demonstrating accountability for quality patient care, and documenting patient care.

All Health Care professionals document their findings for several reasons:

1. Notes record what the clinician does to manage the individual patient’s case. The rights of the clinician and the patient are protected should any question occur in the future regarding the care provided to the patient. SOAP notes are considered legal documents, as are all parts of the medical record.
2. Professionals providing services after the patient is discharged from one clinician’s care may find the clinician’s notes to be very valuable in providing good follow up care.
3. Using the SOAP method of writing notes helps the clinician to organise the thought processes involved in patient care. By thinking in an organised manner, the clinician can better make decisions regarding patient care. Thus, the SOAP note is an excellent method of structuring thinking for problem solving.
4. A SOAP note can be used for quality improvement purposes. Certain criteria are set to indicate whether quality care is occurring. Within a limited time frame, the SOAP notes from all patients with a certain diagnosis can be assessed to see whether the preset criteria have been met.

SOAP is an acronym. Each of the letters in S.O.A.P. stands for the name of a section of the patient note.

The patient note is divided as follows:

S = Subjective

O = Objective

A = Assessment

P = for Plan

During the course of a patient’s care, the patient is initially assessed, reassessed constantly, and finally assessed upon discharge from the clinician’s care.

Each of these types of assessment results in a type of SOAP note. An initial note is written after the initial patient assessment. An interim or progress, note is written periodically, reporting the results of reassessment. A discharge note is written at the time that therapy is discontinued.

The Relationship of SOAP Notes to the Decision Making Process

SOAP notes help the clinician organise and plan quality patient care. Following the SOAP note format presented in this workbook provides structure within which good problem solving can occur.