28 Nov A Medical Student’s Guide to Writing in Soap Notes Occupational Therapy Style
During medical rounds, a student presents a patient to the medical team – which consists of nurses, residents, and attendings. For obvious reasons, the information presented during medical rounds must be accurate, concise, and organized. Medical staff members use a format called SOAP (subjective, objective, assessment, and plan) to document patient information. This type of notation is also necessary to document the progress of a patient during therapy. So, medical students also need to learn how to write in SOAP notes occupational therapy style or physical therapy style (depending on the type of therapy the patient needs).
The Purpose of SOAP Notes
Before learning to write in SOAP format, a medical student should be able to answer the question: “What are SOAP notes?” A SOAP note is a patient-specific documentation that includes admission notes, medical records, and other vital information related to the patient. Many medical practices use templates to plug this information into charts. The purpose of this format is nothing more than an organization. If everyone documented patient information using a different format, medical rounds would become confusing. This way, everyone is always on the same page.
After understanding the purpose of SOAP notes, a medical student can learn to properly document patient therapy progress.
Step One: Interview the Patient
Interview the patient at the start of every therapy session and document the current status of the patient. This documentation is the patient’s opinion of his or her status and nothing more. Always avoid using personal judgment during this stage of the documentation.
Step Two: Observe Patient’s Objective State
This is where you include your professional opinion on whether the patient shows improvement thanks to the prescribed therapy. Document whether the therapy treatment plan seems effective or if you should change the treatment plan.
Step Three: Treatment Plan
Document the plan for the ongoing treatment of the patient. Include changes, expectations, and milestones in the documentation. Include what to look for in terms of signs the treatment plan is not working or needs changes.
The key to writing effective therapy soap notes is in the details. Always follow the format the practical uses and never leave off any important details. In theory, it is always better for SOAP notes to have more information than necessary than for them to lack key information.
Using SOAP Notes Effectively
The process of using the SOAP note format seems involved, but it should never overwhelm you. The purpose of the note format is nothing more than an organization. It makes things easier for the medical staff and protects the patient. Given how many patients you see daily, you cannot always remember every detail about every patient. The SOAP notes are patient cheat sheets. Refer to the notes instead of trying to remember every single detail about every patient.
For medical students, understanding SOAP notes is a vital part of becoming a medical professional. Medical practices, such as clinics and hospitals, cannot function without this format to keep things organized.