If you are studying the medical field and would like to have the best possible experience, learning to take notes the right way helps. Those who don’t follow a proven process will often run into problems and freeze during rounds. They might look through a pile of unorganized notes in hopes of finding relevant information they can present, but you don’t want to put yourself in that position.
You are going to learn about the SOAP format and how it can make your clinical rotations that much easier. Learning how to take proper notes and keep them organized will take you far and keep you on track. Not only can you better serve your patients, but you can also present information in a professional way that lets you stand out from the rest.
Why Use SOAP
Understanding why you should take a SOAP note is a wise step in the right direction if you want to have a positive experience during clinical rotations. SOAP stands for subjective, objective, assessment and plan. It creates a standardized process for collecting and presenting patient information during rounds. SOAP also makes it much easier for health care providers to look up patient symptoms and trace them back to the most likely causes, improving the treatment process for everyone involved.
Many hospitals now use software that organizes patient information in the SOAP format, but not all of them do. You should carry a pen and notebook during your rotations. Even if a hospital has software that stores and organizes notes, you won’t always have time to access it while caring for patients and performing your other tasks.
You always begin your notes by covering the subjective statements of the patient. Experts consider patient feedback subjective because you have no real way to measure what they tell you, but you can use the information they provide to uncover solid facts.
For a SOAP note example, say you have two patients that have cut themselves and lost an equal amount of blood. One patient tells you they lost a little blood, but the other says she lost a lot of blood. You have no way of measuring “a little” or “a lot,” so those terms are subjective. The mnemonic OLDCHARTS helps you remember what to include in your notes.
When speaking with your patients, ask them when they first noticed the symptoms. This lets you know the onset of the symptoms and allows you to establish a timeline you can use to find the source of the problem.
When your mission is to give your patients the best care possible, ask them about the location of their symptoms. If they are in pain, you want to know where the pain first appeared and how bad it is.
The character of the symptoms is another critical factor you must include in your notes. Is the pain throbbing, stabbing, aching or dull?
In some situations, patients will notice they can do things to reduce the pain or other symptoms they have, and anything that improves the symptoms is called an alleviating factor. Ask your patient if the symptoms improve when they sit down or stand up.
Some symptoms remain isolated to certain areas of the body, but others radiate to other locations over time. Whether or not the pain radiates can tell you a lot about the source and help in your effort to treat the condition.
During your rotations, you will discover that some symptoms stay the same while others change. When you want to give your patients the best care possible, ask them if they notice any patterns. You need to know if their symptoms always appear at the same time or when they do certain tasks so that you can craft a viable treatment plan.
Make sure you ask each person under your care about any secondary symptoms or pain that might be present.
Once you complete the first part of your SOAP notes, you move to the objective stage. This section includes symptoms you can objectively observe, such as pulse, blood pressure and respiration. If you examine the patient and discover swelling, discoloration, cuts or anything else, list them as objective observations. Focus most of your time and attention on listing the visible symptoms you see. Although you might want to try and diagnose the patient right away, the objective stage is not the right time for that.
During the assessment of a patient, the health care provider refers to notes taken in the objective and subjective stages to offer a diagnosis. Your assessment might change when you get new information or uncover additional symptoms, but you have to go with the most likely cause at this point.
Some patients might have an obvious condition causing the symptoms. While some will be easy to diagnose, others could have several symptoms or other issues that make it hard to find the source of the problem. Do your best to come up with an answer so that you can move forward to the final stage.
Using the information you have gathered so far, create a plan of action for your patient. In some situations, the plan will be giving your patient medication to treat the condition, but it also includes ordering additional tests to get a clear picture of the patient’s health and well-being.
Some medical professionals forget the importance of communicating with their patients during the planning stage and cause them to feel uneasy. You don’t want to make the same mistake, so make sure you remember to keep your patients in the loop about their treatment. Doing that gives them peace of mind and reduces any fear they might have.
Organize Your Notes
Some medical students take a SOAP note for each patient but don’t keep their notes organized. During rounds, they have trouble giving accurate information about their patients and have a negative experience as a result of their oversight. You can avoid that roadblock by keeping your notes organized at all times.
Rather than listing your notes in the order you discover them, separate them based on the date, severity and the amount of time the patient has had the symptoms. This advice gets you started in the right direction and helps you do rounds without much trouble. Although these tips are helpful, you will eventually come up with your own way of taking SOAP notes that works for you.
If you are anything like most medical students during rounds, you get nervous and feel stressed. You are worried that you will forget a critical detail or make some other mistake that will harm your progress or impact your patient.
Try to remember that nobody expects you to be perfect at this stage, and your mentors will help you improve on areas of weakness. Taking 10 deep breaths before rounds might sound silly, but it can do wonders to reduce stress and help you focus. Ensure that you get plenty of exercise and take time to unwind, and you will come back to rounds feeling better than ever.
Designed to help medical professionals take high-quality notes, SOAP simplifies rounds and gives you a system you can use for the duration of your medical career. Getting in the habit the first time is the hardest part, but it becomes second nature with time. You can ask one of your mentors for a soap note example if you still have questions or need clarification about the process. If you have not yet learned SOAP from one of your instructors, you can impress them by staying ahead of the game.