SOAP Notes - Books and Software for Patient Record Documentation

SOAP notes are a valuable foundation in patient record documentation. While some medical offices and hospitals hand write these notes, they are often transferred into an electronic medical record.

With the increasing importance of complying with federal laws regarding patient documentation and privacy (such as HIPAA), it's incredibly important to have a good record keeping system. Below is an explanation of SOAP notes and some of the options for documenting them.

For those of you new to SOAP notes, the acronym stands for Subjective, Objective, Assessment, and Plan. Below is a brief breakdown of each section.

• Subjective: This section contains the details of the patient's current problem, past medical history, family history, etc.

• Objective: The exam is performed in this section as well as a report of lab and other test results.

• Assessment: This is the current diagnosis based on the above information. Often, previous problems will be listed here, especially if they are relevant to the current problem.

• Plan: This is an outline of the treatment plan and whether the patient needs followup care or tests.
  

SOAP notes aren't just for family medicine or hospital care. Chiropractic offices, physical therapists and massage therapists all benefit from using this format. SOAP notes allow the medical practitioner and office staff to succinctly record information and easily find it in the patient's medical record afterward.

As mentioned, the hand written SOAP note is not obsolete and it probably won't ever be completely. It's a quick and easy way to jot down notes during a therapy session or office visit and enter a more detailed report in the computer later.

To give you an idea of how SOAP note software works, below is a video with a tutorial for a leading chiropractic soap note software company, SOAPe. It may seem daunting at first, but like any program you use continually, it becomes second nature.

Some other software options for different specialties include:

• Quick Notes EMR

• EZNotes for chiropractors

• WinCity for massage and physical therapists

• SydaSoft

You can still buy paper SOAP note templates, print them out from a book, or create your own in your word processing program simply by creating a heading for each section. Also, some of the software companies will have a template you can print out for office use.

Others in your profession can give invaluable insight into the best software for your practice. Also, be sure to check the professional organizations you belong to. Not only are you likely to find someone who uses the SOAP notes method you're interested in, but you may also be eligible for a discount as a professional member.