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SOAP Documentation Template

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The SOAP Note
The SOAP (Subjective, Objective, Assessment, Plan) format has been universally adopted by the medical community as the standard format for documentation. Conveniently, the structure is representative of how the diagnostic and treatment process is typically done. More than that, having a conventional method of documentation allows for easier communication between medical providers. There are several frequently used derivations of this format, but the fundamental elements of “Subjective, Objective, Assessment and Plan” are usually present.
While differential diagnoses are typically not discussed until the assessment portion of the note, consideration of these diagnoses starts with the “Subjective” history taken from the patient and drives what is documented throughout the remainder of the note. Utilizing templates helps providers ensure that they consider the important differential diagnoses and ask appropriate questions while obtaining the subjective history. Templates can also contain reminders of which exam maneuvers to perform that are relevant to the differential diagnoses. By utilizing templates, you can remind yourself to ask all the relevant questions without hesitation. You can move quickly and efficiently through your encounter because you’ve already done most of the work.
Many providers, especially consultants, prefer to list their assessment and plan/recommendations at the top of their note. This allows for other providers to quickly and easily understand their thoughts on the patient and recommendations for workup and treatment. SOAPassist has a “Consult Note” format that changes the SOAP note into a “APSO” note and changes the “Plan” section into “Recommendations.” With the SOAP Note Generator, you can use the same template to make a SOAP note or an APSO note. No cutting or pasting. The SOAP Note Generator does all the work for you. Simply select the templates you want, select the “Consult Note” format and hit “Generate Note.”
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The history and physical is typically documented in one of two ways. The most commonly used format is the problem-based format, which organizes the medical problems in order of significance/severity. The second method is the system-based format, which lists each problem according to its associated organ system. The system-based format is often preferred if there are many problems with several organ systems affected, as is the case with many patients in the Intensive Care Unit (ICU) setting. SOAPassist was created with these formats in mind. Any template saved in the SOAPassist database can be used to generate a note in either of these formats. Furthermore, the SOAPassist SOAP Note Generator will generate a note with the problems in the same order in which they were selected to create the note. Just select the templates you want in the desired order of severity/significance and that is the order they will appear in your note.
SOAPassist also has a procedure note format. This format has the sections that typically comprise a procedure note. While this is likely the simplest of the note formats, it remains a powerful tool as it allows procedure notes to be completed in a moment’s notice. Progress notes can be created from any template format. Users can also create templates specifically for progress notes. For example, you can have a template that addresses specific phases of disease/treatment. You can have a template that specifically talks about transitioning from intravenous to oral diuretics in a patient with a heart failure exacerbation. You can have a template that discusses how all criteria for removing a chest tube have been met and that the plan is to remove the chest tube. SOAPassist has created a method for template utilization that allows users to be as general or as nuanced as is convenient for their practice.

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