SOAP Note Documentation
A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.
Instructions:
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
| S = | Subjective data: Patient’s Chief Complaint (CC). |
| O = | Objective data: Including client behavior, physical assessment, vital signs, and meds. |
| A = | Assessment: Diagnosis of the patient’s condition. Include differential diagnosis. |
| P = | Plan: Treatment, diagnostic testing, and follow up |
SOAP Note Documentation
Submission Instructions:
- Your SOAP note should be clear and concise, and students will lose points for improper grammar punctuation and misspellings.,
- You must use the template provided. Turnitin will recognize the template and not score against it.,
- Complete and submit the assignment using the appropriate template in MS Word,
- Subjective (S) – Review of Systems (ROS):
- If the child is nonverbal or too young to describe symptoms, ensure you document statements from the guardian. Use phrases like “mother states…” or “father denies/admitted…” For example:
- “Mother denies fever chills or weight loss.”,
- “Mother admits to fever and chills no weight loss.”,
- If the child is nonverbal or too young to describe symptoms, ensure you document statements from the guardian. Use phrases like “mother states…” or “father denies/admitted…” For example:
- Social History (SH):
- This section will also look different but still needs to be filled out. Ask the guardian about the living situation such as:
- “Lives in an apartment with no stairs, two parents, and three siblings.”,
- For babies or preschoolers you can put “N/A” for sexual orientation and work status. Instead note their grade level. Similarly, for drug and contraceptive use put “N/A.”,
- For teenagers make sure to ask about and document information regarding sexual activity contraceptive use and drug use.
- This section will also look different but still needs to be filled out. Ask the guardian about the living situation such as:
SOAP Note Documentation
- Screening:
- Adapt the screening section according to the child’s age. While some examples in the template, like mammograms and colonoscopies, do not apply to pediatric patients, there are many age-appropriate screenings to consider:
- Newborns to 12 months: Immunizations, developmental milestones, feeding screenings, hearing tests (if not completed at the hospital), etc.
- 18 to 24 months: Autism screening.
- Older than 12 years: Depression screening
- Dental exam, screening for HPV, Hep B, and HIV if high-risk behaviors.
- Teenage girls (if sexually active): Discuss the need for a pap smear and make a referral to a GYN for the first visit.
- Adapt the screening section according to the child’s age. While some examples in the template, like mammograms and colonoscopies, do not apply to pediatric patients, there are many age-appropriate screenings to consider:
By following these guidelines, you will ensure that your SOAP notes are thorough and appropriate for pediatric patients.
