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Today, the SOAP note an acronym for Subjective, Objective, Assessment and Plan is the most common method of documentation used by providers to input notes into patients' medical records. They allow providers to record and share information in a universal, systematic and easy to read format.

A SOAP note is a form of written documentation many healthcare professions use to record a patient or client interaction.However, all SOAP notes should include Subjective, Objective, Assessment, and Plan sections, hence the acronym SOAP.

Tips for Effective SOAP NotesFind the appropriate time to write SOAP notes.Maintain a professional voice.Avoid overly wordy phrasing.Avoid biased overly positive or negative phrasing.Be specific and concise.Avoid overly subjective statement without evidence.Avoid pronoun confusion.Be accurate but nonjudgmental.

Information gathered in the patient history includes:presence of systemic diseases.previous hospitalizations.previous surgeries.previous anesthetic events (how did the patient fare?)allergies.medications.patient's family history for illness.social history.More items...

SOAPStone Strategy for Written AnalysisSPEAKER. STEP 1: DETERMINE THE SPEAKER.OCCASION. STEP 2: RECOGNIZE THE OCCASION.AUDIENCE. STEP 3: DESCRIBE THE AUDIENCE.PURPOSE. STEP 4: ESTABLISH THE PURPOSE.SUBJECT. STEP 5: INVESTIGATE THE SUBJECT.TONE. STEP 6: DISSECT THE TONE.Jul 26, 2017

Subjective What the Patient Tells you. This section refers to information verbally expressed by the patient. Objective What You See. This section consists of observations made by the clinician. Assessment What You Think is Going on. Plan What You Will Do About It.

Tips for Effective SOAP NotesFind the appropriate time to write SOAP notes.Maintain a professional voice.Avoid overly wordy phrasing.Avoid biased overly positive or negative phrasing.Be specific and concise.Avoid overly subjective statement without evidence.Avoid pronoun confusion.Be accurate but nonjudgmental.