SOAP analysis

Poonam Pant
 SOAP notes
• SOAP notes are a highly structured format for documenting
the progress of a patient during treatment by providers to
input notes into patients' medical records. 

SOAP is an acronym for:

• Subjective - What the patient says about the problem /
intervention.
• Objective - The therapists objective observations and
treatment interventions (e.g. Outcome Measures)
• Assessment - The therapists analysis of the various
components of the assessment.
• Plan - How the treatment will be developed to the reach the
goals or objectives.
 Subjective
• It is in a detailed, narrative format and describes the patient's
self-report of their current status in terms of their current
condition/complaint, function, activity level, disability,
symptoms, social history, family history, employment status,
and environmental history.
• It may also include information from the family or caregivers
and if exact phrasing is used, should be enclosed in quotation
marks.
• The patient's goals and prior response to treatment
intervention, medical information obtained from the patient's
chart are also included.
• It allows the therapist to document the patient's perception
of their condition as it relates to their progress in
rehabilitation, functional performance, or quality of life.
 Subjective
Common errors:
• Passing judgment on a patient e.g. "Patient is over-reacting
again".
• Documenting irrelevant information e.g. patient complaining
about previous therapist.
 Objective
• It includes what the therapist observes, tests, and measures.
• Objective information must be stated in measurable terms.
Using measurable terms helps in reassessment after
treatment to analyze the progression of the patient and
hindering as well as helping factors.
• The objective results of the re-assessment help to determine
the progress towards functional goals, and the effect of
treatment.
• The therapist should indicate changes in the patient's status,
as well as communication with colleagues, family, or carers.
Common errors:
• Scant detail is provided.
• Global summary of an intervention e.g. "ROM exercises
given".
 Assessment
• It includes therapist's professional opinion in light of the
subjective and objective findings.
• It should explain the reasoning behind the decisions taken
and clarify and support the analytical thinking behind the
problem-solving process.
• Progress towards the stated goals is indicated, as well as any
factors affecting it that may require modification of the
frequency, duration or intervention itself.
• Adverse, as well as positive response, should be documented
in re-assessment.
Common errors:
• The assessment is too vague e.g. "Patient is improving".
• Little insight is provided.
 Plan
• Includes anticipated goals and expected outcomes and
outlines the planned interventions to be used.
• Information should be provided concerning the frequency,
specific interventions, treatment progression, equipment
required and how it will be used, and education strategies.
• The plan also documents referrals to other professionals and
recommendation s for future interventions or follow-up care. 
• Changes to the intervention strategy are documented in this
section.
Common errors:
• The upcoming plan is not indicated.
• Vague description of the plan e.g. "Continue treatment".
 Example of a SOAP Note
Current condition:  Hyperlipidemia with Hypertension

• Subjective evidence: Generalized weakness Headache Chest

pain but no radiation
• Objective Evidence:
– Smoke 1 pack/day
– Drinks 90 ml of whisky/day
– BP:144/92 mmHg
– Total Cholesterol 361 mg/dl
• Assessment Diagnosis: Based on the subjective and objective
evidence it is diagnosed as Hyperlipidemia with
Hypertension Etiology: Family History- premature CHD
Assessment of current therapy
• Tab. Atenolol 50 mg 1-0-0
– Category : beta-blocker, Indication : to treat hypertension, Role : it
blocks the beta adrinergic receptor, Dose : 50 mg, ADR'S : Hypo
kalemia , fatigue
• Tab. Pantoprazole 40mg
– Category: proton pump inhibitor, Indication: gastric irritation, Role:
inhibition H+/K+ ATPase enzyme in gastric parietal cells, Standard dose
: 10-40mg, ADR'S: nausea, vomiting
• Tab. Atorvastatin 10mg
– Category: HMG CO-A inhibitor, Indication: hyperlipidemia, Role: it
decrease the cholesterol level by inhibiting the enzyme
• Tab. Furosemide 40mg
– Category: loop diuretics, Indication: hypertension, Role: inhibit Na+Cl-
in ascending loop of henle, Standard dose : 20-80mg, ADR'S: Edema
• Tab. Clofibrate 500mg
– Category: fibrate, Indication: hyperlipidemia, Role: binds with
cholesterol then eliminate, ADR'S: constipation
• Planning
– General goals of treatment:
• Reduce high blood pressure
• reduce cholesterol level
• improve patient quality of life
Thank you !!