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SOAP notes document details from patient visits and let you communicate vital information to other healthcare providers.SOAP notes let you record a patient's initial assessment, diagnosis, and treatment details in a standardized format, which can also be shared with and used by other healthcare providers.

The 4 headings of a SOAP note are Subjective, Objective, Assessment and Plan. Each heading is described below. This is the first heading of the SOAP note. Documentation under this heading comes from the subjective experiences, personal views or feelings of a patient or someone close to them.

The Plan section of your SOAP notes should contain information on:The treatment administered in today's session and your rationale for administering it.The client's immediate response to the treatment.When the patient is scheduled to return.Any instructions you gave the client.More items...?Apr 25, 2018

O: Objective This section is where you document measurable outcomes about your client's performance, including test scores, percentages for any goals worked on, and other quantitative information.

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.

O = Objective or observations. This section includes inspection (e.g., patient still walks with antalgic gait) as well as a more formalized reevaluations such ranges of motion, provocative tests, specialized tests (fixations, tongue, pulse, BP, labs).

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.