Posted by Alyssa Therrien-Coulombe on Sep 30, 2021 2:14:51 PM
Alyssa Therrien-Coulombe

1-Sep-30-2021-05-18-09-90-PM

The SOAP, SOAPIE, or SOAPIER notes are well known in the health field, they are used by physiotherapists, chiropractors, osteopaths, massage therapists, occupational therapists, and many others. They allow professionals to enter all relevant patient information in a standardized and easy-to-read manner. This way, all health professionals will be kept informed of the patient’s condition, the various appointments, and the progress.

The SOAP method was created by Dr. Lawrence Weed in the 1960s. It was a system that allowed notes to be associated with problems identified by a doctor at that time, so it was only part of the documentation process. Soon after, other healthcare professionals began to use SOAP evolutionary notes in their respective fields.

SOAP, SOAPIE & SOAPIER Notes

The difference between these types of notes is the amount of information contained in them, they’re complementary.

We start with the SOAP format, then we can add the IE and finally the R as needed:

SOAPIER

  • Subjective: This is the part where the patient’s observations are recorded. Here, we can find their symptoms, family history, old injuries, lifestyle, health history, etc. It is also possible to include the goal the patient wants to reach with the consultations.
  • Objective: Here you can find information that does not change such as biological sex, age, blood type, apparent injuries, etc.
  • Analysis: This part will contain the professional’s analysis of the data from the subjective and objective parts. This section contains the list of issues, reasoning, treatment goals, treatment direction, etc. It’s where you can do an assessment of a patient’s needs and analyze additional factors that may interfere with the treatment plan to draw conclusions.
  • Plan: Here, you can decide on the plan to adopt in order to achieve the goal set with the patient. You can indicate the duration of the treatment and its frequency, the strategies adopted, and a description of the overall treatment.
  • Intervention: It’s where you can add the interventions carried out since the beginning of the implementation of the plan. Each intervention can be mentioned in detail, it can also include the training prescribed to the patient if there is any.
  • Evaluation: This part includes the evaluation of the effectiveness of the interventions, how the patient reacts, if they see improvements, etc.
  • Revision: The revision part allows you to see if you should change the plan or readjust it according to the results obtained so far.

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Advantages

SOAP note taking has the advantage of being a standardized, widely used method in healthcare. Its format allows notes to be taken clearly and anyone can interpret them quickly. It is also an evolutionary note-taking method that demonstrates all stages of the intervention.

Completing the Note

Giving details when taking notes is essential. Professionals can tend to shorten the explanations, which can lead to vague or missing information. When a third person consults the file, it's essential that they can have access to the relevant information. Here is what should be mentioned in the notes:

  1. The patient’s information about their situation, their symptoms, what led them to consult.
  2. Details of sessions and equipment used.
  3. Changes in the patient’s condition.
  4. Complications or delays during treatment.
  5. Progress towards specific goals.
  6. All communications with the patient, their family or other professionals involved.
PageSOAP

This type of note helps you standardize your files and improve sharing with other professionals who may have to consult the client’s file. These detailed notes will be very useful to you! Of course, there are also different types of notes that are used in the health field, such as POMR notes. The important thing is to find the method that works best for you and that is used most often in your field.


Références

https://www.mycna.ca/~/media/nurseone/page-content/pdf-en/soap_documentation_e.pdf

https://en.wikipedia.org/wiki/SOAP_note

https://www.ncbi.nlm.nih.gov/books/NBK482263/

https://www.physio-pedia.com/SOAP_Notes

Tags: emr, SOAP notes, charting

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