In the healthcare field, healthcare providers document patients’ information electronically or manually in what is called a progress note. As a healthcare provider, you will be required to document a patient’s reason for an office visit, lab results, canceled or missed appointments, and other important patient information in a progress note. One common method of documentation is known as the S.O.A.P note.
“S” stands for subjective information. This is better known as the patient’s chief complaint or reason for the office visit.
“O” stands for objective information. This is your observation. For example, you observe a bruise on a patient’s arm or notice a black eye. The patient may not be good at remembering details when you ask questions. The patient may not maintain eye contact. The patient’s appearance and hygiene may be poor. You smell alcohol on a patient. Objective information also includes vital signs, blood pressures, and laboratory results.
“A” stands for assessment. This is where the physician determines a diagnosis for the patient based on what you have written as the chief complaint or subjective information. The physician will also reach a diagnosis based on observation and the objective information you have written in the progress note, including vital signs and blood pressures.
“P” stands for plan. This is the section where the physician writes what steps to take in order to make the patient better. The physician could write a prescription for antibiotics to treat an infection; request additional laboratory tests or a urinalysis. The physician could perform a medical procedure like a colostomy, a wet mount, or appendectomy, or request you to perform a procedure like an electrocardiogram or spirometry. The physician could also refer the patient to a specialist to better treat the patient. In the plan section, the physician also writes when the patient should return to the clinic.
For this assignment, you will need to detail what information should be included in a S.O.A.P note based on the information that is provided. Please click on the following attachments to view a sample progress note and the actual assignment.