MED ADMN 120 – Fundamentals of Medical Terminology
Student Handout
SOAP Notes
Goal: To understand the basic concept of a SOAP note in theory and practice.
Objective: Student will identify SOAP note abbreviations with accuracy.
Introduction
The SOAP note is an acronym for subjective, objective, assessment, and plan. The
SOAP note is a method of documentation used by healthcare providers to write out notes in
a patient’s chart, along with other common formats, such as the admission note.
Documenting patient encounters in the medical record is an integral part of the practice
workflow starting with patient appointment scheduling, communication between and among
providers, and to “write out notes”, including medical billing and coding. Although there are
other systems that can be used, the SOAP is considered an industry standard.
During the course of a patient’s care, the patient is initially assessed, reassessed constantly,
and finally assessed upon discharge from the physician’s care. Each of these types of
assessments results in a type of SOAP note. An initial note is written after the initial patient
assessment. An interim, or progress, note is written periodically, reporting the results of
reassessment. A discharge note is written at the time that therapy is discontinued.
Writing in a Medical Record
Accuracy: Never falsely, exaggerate, or makeup data. SOAP notes are part of a permanent,
legal document. Incorrect spelling, grammar, and punctuation can be misleading. Objective
information should be stated in a factual manner. “Information” should always be objective.
Brevity: Information should be stated concisely. Use short succinct sentences. Avoid long
winded statements. Abbreviations can help with brevity. Abbreviations used should be from
the accepted list of the facility at which you practice. Brevity can also be overdone. Enough
information must be present to get ideas across.
Correcting Errors: “White out” (correction fluid) should not be used on a medical record.
Trying to destroy or attempting to obliterate information makes it look as if the health
professional is trying to “cover up” malpractice. The proper method of correcting a mistake
make in charting is to put a line through the error, write “error” above the mistake, date it,
and initial it.
Signing Your Notes: You should sign every entry that you make into the medical record. All
notes should be signed with your legal signature. No nicknames should be used.
MED ADMN 120
Fundamentals of Medical Terminology
1 of 5
Course Version 2.0 07/19/2012
Template Version 1.0
MED ADMN 120 – Fundamentals of Medical Terminology
Let’s try an example:
Patient is a 2-day-old male who comes in with his mother for his first visit after birth. He
was a full-term infant, vaginally delivered. Mother provides prenatal history, family history
including the paternal Rh factor and information regarding inherited red cell defects. The
mother says the he has been “very fussy” lately. The baby weighed 5 lb. 7 ounces. His
temperature was 98.6 degrees. His skin was yellowish in coloration, including sclera. The
physician conducted tests which included direct and indirect bilirubin levels. Further tests
revealed gram-negative bacterial infection and serum bilirubin levels at 7mg/dl. The
physician did blood tests for both the mother and the infant for blood group
incompatibilities, hemoglobin levels, the direct Coombs’ test, and hematocrit. After
reviewing the data, the physician felt that the patient has hyperbilirubinemia which was due
to gram-negative bacterial infection. The physician administered an injection of albumin
(1g/kg of 25% salt-poor albumin), antibiotics given for the infection and the physician also
asked that the mother bring the infant in three days so that he could monitor the progress.
In the case study above, there is a great deal of information. Let’s rewrite the information in
the form of a SOAP note.
The Heald Clinic
1234 Vancouver Street, Portland, Oregon 97218 * 503-233-6758
Patient:
Account:
Date:
Blade Connors
CONNBL002
11/08/yyyy
Attending Physician: D. Van White, MD
Subjective (S): Pt is a 2-day-old who comes in for his first office visit after birth. He was a
full-term infant, vaginally delivered. Mother provides prenatal history, family history
including the paternal Rh factor and information regarding inherited red cell defects. The
mother reports that the infant is “very fussy”.
Objective (O): Wt. 5 lb. 7 ounces, T 98.6. Skin has yellowish skin coloration, including
sclera. Tests, including direct and indirect bilirubin levels, reveal gram-negative bacterial
infection and serum bilirubin levels at 7 mg/dl. Blood tests are also performed to test infant
and mother both for blood group incompatibilities, hemoglobin level, direct Coombs’ test,
and hematocrit.
Assessment (A): Hyperbilirubinemia, due to gram-negative bacterial infection
Plan (P):
1. Rx albumin administration (1 g/kg of 25% salt-poor albumin)
2. Rx antibiotics for infection
3. Follow-up appointment in three days
MED ADMN 120
Fundamentals of Medical Terminology
2 of 5
Course Version 2.0 07/19/2012
Template Version 1.0
MED ADMN 120 – Fundamentals of Medical Terminology
D. Van White, MD
VW/mt
D: 11/08/yyyy 09:50:16
T: 11/09/yyyy 12:55:01
(VW stands for the physician, mt, is the person that typed the report, D: is the date of
dictation and the T: is the date it was transcribed, yyyy stand for the current year.)
MED ADMN 120
Fundamentals of Medical Terminology
3 of 5
Course Version 2.0 07/19/2012
Template Version 1.0
MED ADMN 120 – Fundamentals of Medical Terminology
Please answer the following questions:
What does the SOAP acronym stand for?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Why are SOAP notes important?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
SOAP notes/Chart notes are a legal document ___yes ___no
It is fine to use liquid correction fluid as long as the physician says it’s okay. ___yes ___no
When writing a SOAP note, it’s fine to write long exhaustive notes as long as you include all
relevant information. ___yes ___no
Any abbreviations used anywhere can be used in your SOAP notes ___yes ___no. If no,
please explain your answer.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
MED ADMN 120
Fundamentals of Medical Terminology
4 of 5
Course Version 2.0 07/19/2012
Template Version 1.0
MED ADMN 120 – Fundamentals of Medical Terminology
Common Abbreviations Exercise
Using your Medical Terminology Textbook (Appendix B), please identify the following
abbreviations:
AB, Ab, ab ____________________
ac ____________________
Adm ________________________
alt hor_________________
Alt noct _____________________
amt___________________
AODM ______________________
c_____________________
Ca__________________________
CA, ca_________________
Cap, caps____________________
CBR___________________
BIL, Bil, Bili ___________________
Bx, bx__________________
CIS_________________________
COL___________________
COPD_______________________
Dg, dg, dx_______________
DOB________________________
dsg____________________
DOA________________________
DOC___________________
EN, endo____________________
FTND___________________
Gtt_________________________
h_______________________
HBP________________________
gm_____________________
FHT________________________
GB_____________________
HEM_______________________
HPN____________________
Isol_________________________
OB_____________________
OD_________________________
od_____________________
TID, tid, t.i.d.__________________
U/A, UA_________________
Q__________________________
qd, q.d._________________
Qh, q.h._____________________
q 2 h____________________
ANATPHYS 215
Fundamentals of Anatomy and Physiology
5 of 5
Course Version 2.0 12/28/2011
Template Version 1.0