In: Nursing
What are SOAP notes?
SOAP notes
SOAP notes is a material or you can say documentation method used by healthcare providers to make patients chart.documentation of patients unexpectedly meets or encounters in medical records is integral part of pratice workflow.it starts with patients appointment schedule and end with medical billing finally.
SOAP notes includes four parts..subjective,objective,assesment,plan
Subjective parts includes patients recent condition in which they describes about patients main chief complaint and reason for why they came to physician.it includes-onset of injury ,chronology,severity.
Objective part includes documents that are repeatable and traceable facts about patients current status- vital signs, laboratory results,it also includes physical examination such as age and weight of patient,posture ,any abnormalities.
Assesment part includes medical diagnosis of patients for medical visit on given date of note written
Plan includes what the procedure healthcare providers are going to do to treat the patients-referrals,labs ordering and medication prescribed and many more.
So that assessing the patient will be easy to treat them better.