This post will cover
- what are SOAP notes
- why we need to write notes like this
- what to write in each section
- examples of SOAP notes first and second interventions
Hello OT Process readers.
Recently I seem to start my posts with an apology that I have not posted recently and, I must admit, I have NOT posted recently. I have lacked inspiration of late as I have been getting to grips with the world of mental health. It has been really challenging readers, and I felt I couldn’t really help you when I was just keeping my head above water myself.
However inspiration has come in the form of a request from a reader who has asked me to do a post on SOAP notes.
“Could you possibly make a post about SOAP notes and how you would write one when it’s the first time seeing a patient and then a soap note if it’s the second session with the same patient? I find the analysis part difficult after watching their mobility and transfers, especially when having to recommend community OT or reablement. “
What are SOAP notes?
For those who don’t know what SOAP notes are it stands for: Subjective, Objective, Assessment and Planning (Weed, 1970).
Why do we have to write in the SOAP format?
It is important to be competent in the SOAP framework as it is a standard note keeping tool in physical health settings (McCaw & Grant, 2009; Mowery, Wiebe, Visweswaran, Harkema, & Chapman, 2012). It gives the reader a quick understanding of the patients function as SOAP notes are intended to be clear, concise and logical (Gagan, 2009; McCaw & Grant, 2009). I find working through this framework helps me with my clinical reasoning. In my new job (in mental health), staff don’t write in the SOAP format. It tends to be either a narrative account or the nursing staff use an ISoBAR checklist which is a handover-type system. Recently I have started writing SOAP notes again as I miss them. I never thought I would say that, but I do. Lots. It makes note making faster and I like the ‘analysis’ bit where you can talk about what you make of the situation rather than describe what happened in a narrative format and the back and forth that this approach involves.
What to write in SOAP notes
Subjective (What is SAID)
Write in this section anything that someone says to you or reports. This can be the patient, a relative, or a member of the MDT. This can be face to face or on the phone. The type of stuff that goes in this section includes:
- Consent to treatment
- Social history from patient or family member
- how the patient says they are feeling
- client goals and wishes on discharge
Objective (What you have OBSERVED)
This is anything that you’ve seen. In the objective section write your observations, results of standardized and non-standardized assessments, range of movement, initiation of task, distance of mobilisation, assistance levels and equipment required (Smith, 2013).
Analysis (your ASSESSMENT)
OK, so taking into account what you’ve heard and what you see; what do you make of it all? Summarise your clinical reasoning by writing the conclusions that you have reached from the subjective and objective and how they are affecting the clients occupational function (Gagan, 2009). For example: that fear of falling and sacral pain is restricting movement or that the patient mobilises easily with a gutter frame therefore progress to a wheeled Zimmer frame.
Right, as a result of your analysis, what needs to be done? End with a statement justifying the continued need for OT input if required. In the plan I write any updated goals, modifications to therapy and subsequent treatment sessions (McCaw & Grant, 2009). For example an environmental assessment, to review the patient in two weeks, or a planned discharge date.
Argh! I’ll never get all this!
Don’t be hard on yourself, you won’t get this straight away, it’s a skill that takes practice to master. As a student I used to write my notes in rough first as I would end up with so many crossings out. I would remember something that should have gone in subjective but I had already started writing the objective section. I found it useful for a bit to start with objective as it was always the subjective that I kept wanting to add more to as I remembered things.
Writing a first interview in SOAP notes.
How you’ll do this will depend on your trust or your department; on the physical wards, I would often do this as a joint assessment with the physiotherapist. In my last trust we usually had an ‘initial assessment’ form where we would write on and then in the medical notes I would write “see OT assessment dated 01/12/17”. If you don’t have this then this is what I would include:
- Date and time
- Your name, grade, profession and ward, also if any other professionals were present.
- Add if any family members were present and their name and relation to the patient.
- Consent gained
E.g. 11/11/17 14:20.OCCUPATIONAL THERAPY H.Otprocess B5 OT, Ward A, seen with J.Physio B6PT. Also present Jane (niece). Consent gained as per trust guidelines
- How patient reports they are feeling (any pain/fatigue voiced Etc.)
- The main part of the initial interview is the social history, see the post ‘Honing your initial interviews’ for a full description of what you information you require for a full social history.
- who they live with or if they live alone
- Type of property (house/flat/bungalow), whether they rent or own the property, if it’s rented-who do they rent it off (e.g. private landlord, housing association, council).
- Do they live in sheltered accommodation?
- Do they have a package of care (POC)? If so how many calls do they have a day? What do the carers help with? (see my post on how to decide on a POC for a patient)
- Do they have any adaptive equipment at home?
- Do they have a falls alarm?
- Do they usually walk with an aid? Indoors and outdoors.
- Do they transfer independently on and off chair/bed/toilet?
- Do they have stairs? How many rails? Any difficulty with them?
- Does someone help them with or can they do independently washing, un/ dressing, meals, cleaning, housework, laundry, and shopping.
- Do they wear pads? Do they usually get up during the night to go the loo?
- During the assessment did they ask you to help them with something? E.g. requested for you to help them in the bathroom.
- If you’ve spoken to a relative to corroborate the social history, write what they have said or any concerns/comments voiced by family members
- Ask the nursing staff how much assistance the person has required getting washed and dressed and write it here.
- Where were they on arrival to ward? (E.g. in bed on arrival, sat out in chair)
- Any attachments (e.g. catheter, nasal specs, drain, IV)
- Mobility, gait, and how many people did it need for them to mobilise safely and with what mobility aid? (e.g. max assistance of 2 with gutter frame, supervision of 1 with wheeled Zimmer frame)
- Distance walked, how many rest breaks that they had to take. Did you have to walk with a chair behind them?
- Transfers: chair/ bed/toilet. How much assistance required? Any rails or equipment used? If they transferred from a hospital bed was the back rest up? Did they grab onto the side rails. You may want to note any chair/bed/toilet heights here.
- Any range of movement (ROM) or muscle power test (Oxford scale) that you may have done with the physio or things like ‘Timed up and go’ test or Barthel Index.
- Demeanor and/or cognition(e.g. slightly confused, agitated, shouting out, fearful, alert, drowsy, delayed)
- Anything else you’ve noticed ( e.g. tremor, swollen legs, shortness of breath)
If this is the first interview, together with the physio (depends on how you do it at your workplace), you may decide what aid and how much assistance the patient requires at this moment so nursing staff know how to mobilise the patient
- Are they back to their pre-admission baseline? How far are they off baseline? Remember you don’t have to get patients back to baseline before you can discharge them; it’s about making sure that they can manage at home. But it’s good to make an assessment on how different they are to their usual presentation.
- Can they go home if they are medically fit for discharge?
- Do they need further assessments e.g. kitchen ax or washing and dressing?
- Do they require a POC? Have they got the potential to reduce care calls over a period of time? If so refer to Re-ablement (see this post on POC’s)
- Do they require equipment for home? Is this essential for discharge?
- Will they need further rehab?
- If you have decided on rehab, what should their goals be? The goals are usually things like;
Mobilise x metres with (walking aid) in x weeks
Transfer independently chair/bed/toilet with x adaptive equipment in x weeks
Independent with stairs and bilateral rails in x weeks
Rehab goals are usually around mobility, transfers and stairs. Remember, when you’re writing rehab goals that people don’t need to be independent with washing, dressing, meals etc. as you can always get a POC (unless the patient is adamant that they do not want anyone helping them with this).
- Do you need anyone to do anything (e.g. further physio work on mobility or request that the physio does a stair ax, social worker to assess for a POC, nursing staff to do lying-standing blood pressure or medics to do a MMSE?).
I’ve included types of things that I would write in a plan:
- Further mobility/transfer practice
- Progress onto wheeled Zimmer frame
- Assess with a piece of equipment
- Referrals to rehab or other services
- Anyone you need to do anything?
- Stair assessment
- Functional assessments
- Cognitive assessments
- Order equipment?
- Home visit needed?
- Are you awaiting anything? E.g. POC? Or any medical tests?
- Reported mood/pain
- any changes (hopefully improvements) the patient has reported since they last saw you
- Ask nursing staff if any changes in mobility, washing and dressing etc.
Same as first interview, on the ward this pretty much stays the same unless you are doing something specific like functional assessments, or cognitive tests.
- Have they made progress or declined since last time?
- If they have declined is there something that could be affecting function? E.g. medical condition deteriorated, not had analgesia recently, not had Parkinson’s meds, urinary tract infection, delirium or lack of compliance.
- Can you now progress them onto a different walking aid?
- Do they need a piece of equipment
- Do you need to change your plan or does the plan remain the same?
- Generally similar type things to the first interview, but you are looking at what’s changed since last time
So I hope you’ve found this post useful on the types of things that you can put in SOAP notes. It’s always useful to look at how other OT’s do it and copy things that you like or find helpful. I generally prefer bullet pointed get-to –the-point notes as time is precious on the wards and you want to be able to read and understand notes quickly. Remember; well written notes promote the profession and the value of occupational therapy (Smith, 2013).
The OT process will take a little break for a while so all the best for Christmas and I will see you in 2018. Please feel free to contact me with any suggestions for posts for either physical or mental health.
Gagan, M.J.(2009). The SOAP format enhances communication:the SOAP format provides a clear and concise way of documenting patient information. Retrieved from http://www.thefreelibrary.com/The+SOAP+format+enhances+communication%3A+the+SOAP+format+provides+a…-a0203135224
Mc Caw, L., & Grant, J. (2009). Record and report writing. In E.A.S Duncan (Ed.). Duncan, E.A.S. (2009). Skills for practice in occupational Therapy (pp.191-208).Edinburgh: Churchill Livingstone
Mowery, D., Wiebe, J., Visweswaran, S., Harkema, H., & Chapman, W.W. (2012). Building an automated SOAP classifier for emergency department reports. Journal of Biomedical Informatics, 45(1), 71-81. Retrieved from http://www.j-biomed-inform.com
Smith, J. (2013). Documentation of occupational therapy services. In H. McHugh Pendleton & W. Schultz-Krohn (Eds.). Pedretti’s Occupational Therapy: practice skills for physical dysfunction (7thed.)(pp. 117-139). St Louis: Elsevier
Weed,L. (1970). Medical records: Medical education and patient care the problem-oriented record as a basic tool. Cleveland: Year Book Medical Publishers Press of Case Western Reserve University Cleveland