Can a Subjective, Objective, Assessment, and Plan (SOAP) note be created for a patient?

From the Guidelines

You can create a SOAP note based on a patient, which is a crucial documentation method for recording patient information in a structured format. A SOAP note is a documentation method used by healthcare providers to record patient information in a structured format. SOAP stands for Subjective (what the patient reports), Objective (measurable findings from examination), Assessment (diagnosis or clinical impression), and Plan (treatment approach). To create a SOAP note, you would first document the patient's chief complaint and history in the Subjective section. Next, record vital signs, physical exam findings, and test results in the Objective section. Then, formulate your clinical impression or diagnosis in the Assessment section. Finally, outline the treatment plan including specific medications with dosages, follow-up instructions, and patient education in the Plan section, as recommended by the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation writing group 1. Some key points to consider when creating a SOAP note include:

• Composing written records that reflect the patient evaluation and contain a patient care plan with detailed priorities for risk reduction and rehabilitation, as outlined in the study by the American Heart Association 1
• Actively communicating this plan to the patient and the primary healthcare provider, which is essential for ensuring continuity of care and reducing morbidity and mortality
• Ensuring that the SOAP note is a standardized, comprehensive record of patient encounters that facilitates clear communication among healthcare providers. For example, if prescribing a medication, you would specify the medication, dosage, and frequency, and also include any necessary follow-up instructions or patient education. By following this structured format, healthcare providers can ensure that patient information is accurately and consistently documented, which is critical for providing high-quality patient care and improving outcomes.

From the Research

Patient Information

To create a SOAP (Subjective, Objective, Assessment, Plan) note for a patient, we need to consider the patient's medical history, current symptoms, and treatment goals.

Subjective

• The patient's subjective experience of their condition, including any symptoms they are experiencing, such as headaches or dizziness 2
• The patient's medical history, including any previous diagnoses or treatments for hypertension 3

Objective

• The patient's blood pressure readings, including systolic and diastolic blood pressure 2
• The patient's lifestyle habits, including diet, physical activity level, and alcohol consumption 3, 4
• The patient's current medications, including any antihypertensive medications they are taking 5, 6

Assessment

• The patient's risk factors for cardiovascular disease, including high blood pressure, diabetes, and high cholesterol 2, 5
• The patient's current blood pressure control, including whether their blood pressure is at or below the target level 2, 6
• The patient's adherence to lifestyle modifications, including diet, physical activity, and stress management 3, 4

Plan

• Lifestyle modifications, including:
  • Dietary changes, such as reducing sodium intake and increasing potassium intake 2, 3
  • Increasing physical activity level 3, 4
  • Stress management techniques, such as meditation or deep breathing 4
• Medication management, including:
  • First-line antihypertensive medications, such as thiazide diuretics, angiotensin-converting enzyme inhibitors, or calcium channel blockers 2, 5
  • Combination therapy with multiple antihypertensive medications, if necessary 5, 6
• Monitoring and follow-up, including regular blood pressure checks and adjustments to the treatment plan as needed 2, 6