Using the Subjective, Objective, Assessment and Plan (SOAP) format of charting standardises the amount and type of information that is written into medical records. Using this process of evaluation enables medical staff to address specific problems, as well as note the evaluation process and resolution. When health care organisations use the SOAP format, each patient chart, whether online or on paper, is populated with pre-printed forms or formats that outline the SOAP method of charting, making it easy for health care practitioners to follow this intuitive process.
- Skill level:
Things you need
- Blood pressure monitor and cuff
- Pulse oximeter and probe
Ask the patient, "Are you in pain?" Subjective comments are the comments the patient has said herself, most often in response to your question. Additional questions you might ask include are you nauseous, vomiting, have a headache, are you urinating, walking, how do you feel, any chest pain or chest tightness? All of these questions are subjective and should be noted as such. "Patient states that she is not in pain, urinating frequently, has a mild headache and has no appetite."
Make objective comments that you observe to be true, such as "patient is alert and resting comfortably." Record breath sounds; listen to the patient's lungs and chart what you hear; "Faint wheeze in right upper lobe, left lung clear." Take and chart the patient's body temperature, blood pressure and oxygen saturation, for example, "Temp is 98.6, BP is 120/89, POX, Pulse Oximetry or oxygen level, is 98 Percent, pulse 78."
Assess the patient's present condition and determine a diagnosis. An assessment also entails any new or developing symptoms or previous response to treatment. Include whether the condition is acute, chronic or recurrent. For instance, "Patient's acute asthma symptoms have subsided; patient no longer needs Q4 breathing treatments."
Detail the course of action based on your subjective and objective comments and the assessment through the care plan, most often established by the patient's physician. For instance, "Patient can be discharged with Albuterol metered dose inhaler with referral to asthma management clinic, follow-up in 10 days."
Tips and warnings
- Be as accurate as possible in all charting.
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