How to write Clinical Notes

Posted on: 2019-05-25

The method discussed here is SOAP. The  SOAP note (an acronym for subjectiveobjectiveassessment, and plan) is a method of documentation employed by health care providers to write out notes in a patient’s chart, along with other common formats, such as the admission note. Documenting patient encounters in the medical record is an integral part of practice workflow starting with patient appointment scheduling, to writing out notes, to medical billing .

Subjective component (S)

Purpose of visit or hospitalization. In this part, one will take a history of present illness, or HPI. This describes the patient’s current condition in a narrative form.

The mnemonic below refers to the information a physician should elicit before referring to the patient’s “old charts” or “old carts”.

  • Onset
  • Location
  • Duration
  • CHaracter (sharp, dull, etc.)
  • Alleviating/Aggravating factors
  • Radiation
  • Temporal pattern (every morning, all day, etc.)
  • Severity
  • Chronology (better or worse since onset, episodic, variable, constant, etc.)
  • Modifying factors (what aggravates/reduces the symptoms—activities, postures, drugs, etc.)
  • Additional symptoms (un/related or significant symptoms to the chief complaint)
  • Treatment (has the patient seen another provider for this symptom?)

Objective component (o)

Includes information that the healthcare provider observes or measures from the patient’s current presentation.

Vital signs and measurements, such as weight.

  • Findings from physical examinations, including basic systems of cardiac and respiratory, the affected systems, the possible involvement of other systems, pertinent normal findings and abnormalities.
  • Results from laboratory and other diagnostic tests already completed.

Assessment (A)

A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in the order of most likely to least likely.

Plan (P)

The plan is what the health care provider will do to treat the patient’s concerns—such as ordering further labs, radiological work up, referrals are given, procedures performed, medications given and education provided.

This sums up the SOAP procedure for writing a clinical note for the patient