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Soap Notes- Making Paperwork Easy

By Julia Roger Subscribe to RSS | January 31st 2012 | Views:

A soap noteA soap note is an acronym for Subjective, Objective, Assessment and Plan. In the field of medical assistance, this particular term refers to a form of quick documentation that charts the history of the patient’s reaction to the treatment given to ways in which the additional assistance may be given to the patient. Paralleled with SWOT, long hand and admission note, a soap note focuses on methods that would ensure the quick recovery of the patient.

A soap notesoap note proceeds in a systematic manner of in a four- steps way. The first step is titled as ‘Subjective’. Comprising of patient’s core complaint, it is formulated on the basis of the patient’s own words. This component also adds to this personal statement with the medical history of the patient. The second step Objective makes notes of the vital signs of the patients as well as the physical tests taken by the patient in relation to the illness. There is no opinion involved at this stage which focuses on collecting only medical data. The third state Assessment takes into account the first two stages – the subjective and objective and makes an informed judgment of the progress made by the patient, any persisting worries and related diagnosis that can be done. The last stage is the future Plan of action that the doctor formulates.

Brief and succinct the soap note functions as the frame of reference for the medical assistants and the doctors while they are working on the patient. It is not as detailed as the progress report nor as miniature as the admission note basing its focus on observation. The writing is supposed to be precise which demands certain skill and practice.

Since the advent of computers, the world has become driven to create a paperless existence. The soap note is similarly impacted by that drive. Today you can find templates that are designed for the convenience of the medical personnel. It is easy to use and gives the advantage of making the professionals more focused on their work and not on spelling mistakes.

Julia Roger - About Author:
For more information on soap notes, check out the info available online; these will help you learn to find the therapy software!

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