SOAP Basics

Objectives
● To identify the structure and language used in SOAP notes and medical
charts
● To dissect each section to identify essential terminology and acronyms
● To build a set of language-specific and medical terminology resources
● To replicate the style and voice of healthcare professionals in your
medical translations
 SOAP Notes:
An Introduction
What is a SOAP Note?
A SOAP note is a structured form of “progress note” to it ensures meaningful
data, rather than narrative charting, such as “patient appears to be resting”

S- Subjective

O- Objective

A- Assessment

P- Plan
(S)ubjective
● Patients chief complaint (CC) or the history of present illness (HPI)
○ This is the purpose of the patients visit
○ The “OLD CARTS” mnemonic device is used by doctors to help guide them in gathering subjective information:

Onest Character (sharp, dull, etc.)

Location Alleviating/Aggravating factors

Duration Radiation

Temporal pattern

Severity
(O)bjective
● Information gathered by the doctor, through observation or
measurement including:
○ Vital signs ( weight, temperature, heart rate, respiratory rate)
○ Physical exam
○ Laboratory tests
○ Prescriptions
(A)ssessement
● This is the medical diagnosis or the purpose of the visit:
○ Assessment of the situation, even if obvious based on subjective/ objective statements
○ Includes possible and likely aetiologies
○ Does not repeat the subjective and objective portions, but takes key points and puts
them together into a conclusion
(P)lan
● What the doctor will do to treat the patient’s concerns and based on the
assessments:
○ Ordering lab tests, radiology work-ups
○ Referrals, discharge, future appointments, etc.
○ Prescriptions, monitoring
○ Numbered by severity and urgency
Purpose of SOAP Notes
● Liability: legal document
● Communication: method to communicate with other healthcare
professionals and/ or your staff
● Insurance: third party reimbursement
● Progress Report: Review report to decide if Tx is effective
● Research: to collect injury data statistic
● Education: to improve quality of care
SOAP Notes
● Write it as soon as possible before it fades from your memory
○ May have to take notes during the evaluation initially
● Notes should be organized and chronological
○ Use subheadings
○ Underline headings
● Notes should include past and present examinations, tests, Tx and
outcomes
SOAP Notes
● Notes must be legible
● Never use “I” refer to the professional title
○ Ie. DVM
● Use quotes whenever possible
● Do not use hyphens
○ Confused with minus signs
● Use black or blue ink only
● Sign all evals and progress notes
SOAP Notes: Section by section
(S)ubjective
● Information you collect directly from the patient
● Avoid injecting your own assessments and interpretation
● Needs to include
○ Patients chief complaint
○ The history of the patient's present illness, as reported by the patient
○ Pertinent medical history
■ Past medical and surgical history
■ Family history
■ Social history
○ A current list of the patients medications, including
Do Dont the doses and frequency of administration

Use the present tense USe past tense or mix tenses

Expand acronyms for 1st use Fail to translate acronyms
Research correct usage for your target Directly translate acronyms
(O)bjective
● Begins the moment the doctor first sees the patient
○ Assess the individual's state of consciousness and body language
■ May indicate pain, disability, fracture, dislocation, or other conditions
○ Note their general posture, willingness and ability to move
● Start with the patient's vital signs
● Transition to the physical exam
○ General impression of the patient
○ Followed by
■ Head , ears, eyes, nose, and throat
■ Respiratory, cardiac, abdominal, extremity, and neurological exams
● Report the results of any other diagnostics that have been performed
(O)bjective
● What to avoid
○ Do not include general statements without supporting data
■ For example “client responded well to non-verbal cue”
● Calls for more specificity
○ When discussing specific clinical interventions, the intention of the intervention and its
connection to the larger treatment plan should be clear
■ Avoid verbs like “discussed” pr “explored” as it’s not inherently clear what the
purpose of such discussion or exploration would be.
Do Don’t

Stay objective: signs and symptoms USe “diagnostic” language

Use plain language Turn phrases into wordy sentences
Use correct register (doctor- facing) Use lay medical terminology
(A)ssessment
● Diagnosis or condition the patient has
● Professional opinion of the type of injury/illness
● Based off the subjective and objective portions of the exam
● There maybe one clear diagnosis or several things wrong
● Other times where a definitive diagnosis is not yet made, and more than one possible diagnosis is
included in the assessment
● Must include
○ Anatomical location
○ Severity
○ Description
● Use this section to describe doctors analysis, interpretation of the session and doctors client progress
toward the goals defined in the treatment plan
● Document strengths and areas of improvement, and compare performance to previous sessions
(A)ssessment
● Craft one- to two sentence summary that includes the patients species,
breed, age, sex, spayed/nuetered, relevant medical history, major
diagnosis and clinical stability.
● If the patient has multiple major diagnoses, these should all be
mentioned in your summary statement.
● If your patient is experiencing any new symptoms, be sure to include a
differential diagnosis as well
○ Aim to include at least two or three possible diagnoses.
(A)ssessment
● Handle acronyms appropriately
○ Target audience of your translation may not be a healthcare professional
○ Expand acronyms and do not assume your target will know even obvious signs/symbols
● What to avoid
○ Do not rewrite what has already been stated in the subjective or objective sections

Do Don’t

Be methodical with conjunctions Beware of conjunctions that do not have

the same “logical link” in the source and
target
(P)lan
● Treatment the patient will receive that day
● Plan for further assessment or reassessment
● Client education: Home instructions
● Referral
● Short and long term goals: need to be measurable
● Expected functional outcomes
● Equipment needs
● Plans for discharge
(P)lan
● Create a list of all of the patient's medical problems
○ Your list should be ordered by acuity
● Propose a plan to manage each problem the doctor has identified

Do Don’t

Use imperative or present test Use passive voice

Double check Rx names, doses Use latin in prescriptions
Progress Notes
Progress Notes
● Written after each recheck/progess check
● Can be performed as SOAP note or as a summary
● Include response to Tx and type of TX
● Progress made towards short-term goals
● Changes in TX or goals
● Important notes
○ Seen by doctor
○ Results if diagnostic tests
Progress Note- Subjective
● Response to treatment
○ Decrease/increase pain
■ Include why
■ Overall psychological profile
● Reassessing subjective information from previous notes
○ Change in function
○ Change in pain
● Client compliance issues
Progress Note- Objective
● Tx provided
● Reassess and compare measures that may have changed
● Note changes
● Indicate any changes or special notes for treatment
References
● https://slideplayer.com/slide/7373795/
● https://www.globalpremeds.com/2015/01/02/understanding-soap-format
-for-clinical-rounds/
● https://www.wolterskluwer.com/en/expert-insights/what-are-soap-notes
● https://www.simplepractice.com/blog/4-mistakes-to-avoid-when-writing-s
oap-notes/