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Today, it is widely adopted as a communication tool between inter-disciplinary healthcare providers as a way to document a patient's progress. SOAP notes are commonly found in electronic medical records (EMR) and are used by providers of various backgrounds.

The SOAP (Subjective, Objective, Assessment and Plan) note is probably the most popular format of progress note and is used in almost all medical settings.

Most healthcare clinicians including nurses, physical and occupational therapists and doctors use SOAP notes. As a med student, you also need to use a SOAP note format. The purpose of a SOAP note is to have a standard format for organizing patient information.

Nurses and other healthcare providers use the SOAP note as a documentation method to write out notes in the patient's chart. SOAP stands for subjective, objective, assessment, and plan.

Subjective What the Patient Tells youTake note of the patient 's complete statement and enclose it in quotes. Recording patient history such as medical history, surgical history, and social history should also be indicated as it can be helpful in determining or narrowing down the possible causes.

However, all SOAP notes should include Subjective, Objective, Assessment, and Plan sections, hence the acronym SOAP.

O = Objective or observations.

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.

5 Tips for Writing Better Therapy NotesBe Clear & Concise. Therapy notes should be straight to the point but contain enough information to give others a clear picture of what transpired.Remain Professional.Write for Everyone.Use SOAP.Focus on Progress & Adjust as Necessary.Aug 13, 2020

Progress Notes entries must be:Objective - Consider the facts, having in mind how it will affect the Care Plan of the client involved.Concise - Use fewer words to convey the message.Relevant - Get to the point quickly.Well written - Sentence structure, spelling, and legible handwriting is important.