SOAP charting has become one of the newest tools in healthcare these days. SOAP stands for subjective, objective, assessment, and plan.
This has become a way to improve communication among healthcare workers by putting the most relevant information about a patient in one place. The goal is to be more efficient and avoid errors and inaccurate information about patients. Of course, to use SOAP charting efficiently, it’s critical for healthcare workers to understand each of the four parts of SOAP charting to ensure all pertinent information is included but not repeated. With that in mind, let’s take a closer look at the four parts of SOAP charting.
Subjective
The first part of the SOAP chart should include all relevant information about the patient. This should begin with their chief complaint for seeking a healthcare professional, as well as any secondary complaints that could be relevant as well. The patient’s history should be taken down, including the onset of the symptoms, and severity of those symptoms, and how those symptoms are impacting the patient’s quality of life. Any medications they’re taking, past medical issues, or environmental factors should also be noted in this part of the SOAP chart. Just like all other parts of the SOAP chart, it’s best to be as pithy as possible. However, all relevant information should be included. Also, it’s not a bad idea to quote directly from the patient as they describe their problem because this can prevent any editorialization of a patient’s symptoms.
Objective
The second part of the chart is for making observations and sharing factual information. This can begin with a patient’s vital signs and anything that can be ascertained from a physical exam. If there are previous lab tests or images, the second portion of the SOAP chart is where to include the results. It’s also helpful to include observations about a patient’s behavior. This can include their body language, demeanor, posture, and how much talking they’re doing. However, keep in mind that these should be observations only, meaning healthcare workers should resist the urge to editorialize or jump to conclusions about a patient’s behavior or medical data.
Assessment
The third part of a SOAP chart should serve mostly as a summary of the first two sections. Use clinical language to create a clear assessment of the situation. What is the problem? What are the patient’s symptoms? What is the patient’s current status? In this part, it’s critical not to write anything that doesn’t have substantial evidence. It’s also best to keep this section to two or three sentences depending on how much information was gathered in the first two sections.
Plan
The final part of the SOAP chart will explain the next step in the process. What is the plan moving forward for treating or managing the patient? Is more information needed? Will the patient need additional treatment? If a patient has more than one medical problem, there should be an individual plan for each separate problem to ensure that everything is being addressed and nothing has been overlooked.
Always Think About Safety
Obviously, healthcare professionals are usually concerned with the well-being of patients. But the health and safety of healthcare workers is also important in any healthcare setting. This is why the safety management software from EHS Insight is relevant and available to organizations across all sectors. Our system was created to manage employee health and safety on a single platform, helping to keep things organized and avoid anything related to worker safety from being overlooked.
If you want to make sure that your employees are being cared for while on the job, call us and we can talk more about how our software can help you improve employee health and safety.
