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If you’re a nurse practitioner, then you know that writing SOAP notes is a vital part of documenting patient care. But what exactly should you include in a SOAP note? And what should you avoid?
In this blog post, we’ll take a look at what makes a good SOAP note, including what insurance companies look for. We’ll also give you some tips on what to avoid using in your SOAP notes. So let’s get started!
What is a Soap note as a nurse practitioner?
A SOAP note is a documentation method used by healthcare providers to record important patient information. The acronym stands for Subjective, Objective, Assessment, and Plan. This type of note is usually used in the medical field but can be beneficial for other health-related fields as well.
The subjective portion of the SOAP note includes information that the patient tells the healthcare provider. This can include symptoms that the patient is experiencing, as well as how these symptoms are affecting their daily life. It is important for the healthcare provider to document this information accurately so that they can get a clear picture of what the patient is dealing with.
The objective portion of the SOAP note includes information that the healthcare provider observes about the patient. This can include vital signs, physical exam findings, and lab results. This information helps to give a more complete picture of the patient’s condition.
The assessment portion of the SOAP note is where the healthcare provider makes a determination about the patient’s condition based on all of the information that has been gathered. This can be a diagnosis, or it can be a plan for further testing or treatment.
The plan portion of the SOAP note outlines what the next steps will be for the patient’s care. This can include medication orders, referrals to other specialists, or instructions for follow-up appointments.
SOAP notes are an important part of documenting patient care. They help to ensure that all important information is captured and that everyone involved in the patient’s care has a clear understanding of what is going on.
What should be included in the Soap note
When writing a SOAP note, there are four main sections that should be included:
Subjective: This is where the patient’s symptoms and concerns are described. This information is typically gathered through interviews and observation.
Objective: This section includes any relevant information that can be observed or measured, such as vital signs, physical exam findings, or lab results.
Assessment: In this section, the clinician forms a working diagnosis based on the information gathered in the subjective and objective sections.
Plan: The plan outlines the treatment or management plan for the patient, including any referrals that may be necessary.
What insurance companies look for in soap notes
When it comes to insurance companies, they are looking for a few key things in soap notes. First and foremost, they want to see that the patient was seen and that all required tests and treatments were completed. They also want to see that the diagnosis is clearly stated and that the treatment plan is appropriate for that diagnosis. In addition, insurance companies often have their own guidelines that must be followed in order for reimbursement to be approved, so it is important to be familiar with these guidelines when writing soap notes.
What should never be used in a Soap note
When writing a SOAP note, there are certain things that should never be included in order to avoid any potential legal issues. For example, personal information about the patient that is not relevant to their medical care should not be included. In addition, any information that could potentially identify the patient should also be omitted. This includes the patient’s name, address, and date of birth. Any information that could lead to discrimination against the patient should also be avoided.
- Problem Statement (Chief Complaint)
- Subjective (History)
- Objective (Physical Exam/Diagnostics)
- Assessment (Diagnoses)
- Plan (Orders)
- Rationale (Clinical Decision-Making)
Example:
Chief Complaint:
“I feel awful…I’m exhausted, short of breath, my fever is getting worse.”
HPI:
Marvin C. Webster is an 18 yr old male who recently had the influenza virus two weeks ago which resolved, and today presents with a four-day history of sudden onset fever 103.2, with chills, rigors, myalgia, productive cough without wheezing, fatigue, and sharp right-sided pleuritic chest pain that is aggravated with coughing and breathing. He reported a fever of 104 last night and took OTC Ibuprofen with no significant improvement in his symptoms. He complains of a productive cough with green/yellow sputum with no relief after taking cough syrup. Pt denies any recent travel or sick contacts. The patient reports he takes no daily prescription medications or additional OTC medications.
ROS:
Constitutional: Positive for fever, chills, rigor, and fatigue. Negative for appetite change, and diaphoresis.
HEENT: Positive for swollen glands; negative for headache, sore throat, and difficulty swallowing
Respiratory: Positive for dyspnea, productive green/yellow sputum, and shortness of breath, negative for wheezing
Cardiovascular: Positive for right-sided chest wall pain (6-8th intercostal spaces at the midaxillary line), negative for leg swelling
Gastrointestinal: Negative for rectal bleeding, blood in stool, constipation, diarrhea, nausea or vomiting
Endocrine: Negative for polydipsia and polyuria
Genitourinary: Negative for decreased urine production, menstrual problem, pelvic pain, urgency or vaginal discharge
Musculoskeletal: Positive for myalgia, negative for back pain, neck pain and neck stiffness
Allergic/Immunologic: Negative for food allergies
Neurological: Negative for seizures, facial asymmetry and speech difficulty
Psychiatric/Behavioral: Negative for confusion, dysphoric mood and sleep disturbance. The patient is not nervous/anxious and is not hyperactive
PMH:
Childhood asthma, not currently under treatment
FMH:
Mom – HTN
Social hx:
College student denies tobacco use, admits to occasional social drinking, not sexually active, no illicit drug use
Current Medications:
OTC Ibuprofen
OTC cough syrup
Allergies:
No known drug allergies
Vital signs:
Temp: 103.2 F
Pulse: 120 bpm
BP: 120/80 mmHg
RR: 24 bpm
O2: 91% RA
Physical Findings:
General: Alert and oriented x 4, calm, cooperative
Skin: pink, warm and dry; no rash, lesions, or icterus; tenting of the dorsal hand
HEENT: Head normal, atraumatic; normal conjunctiva, no scleral icterus, clear right and left tympanic membranes; exudative pharyngitis, no palatal petechiae
Neck: Tender 1.0-cm to 1.5-cm anterior cervical lymph nodes, neck supple, full range of motion
Lymphatic: Tender anterior cervical adenopathy; no posterior nodes palpable; no other regional lymphadenopathy
Chest wall and lungs: Bibasilar pulmonary crackles, tachypnea, hypoxia
Heart: Sinus Tachycardia
Abdomen: soft, non-tender; no hepatosplenomegaly
Extremities: no swelling or deformity; no cyanosis, clubbing or edema
