SOAP note or form is a way in which the doctor’s document patient complaints along with other relevant medical details and kept as a record for future reference. This is considered as a very important step in medical documentation as this gives a complete picture of the patient’s medical history. They are most popularly used as an easy and effective form of medical procedure documentation in medical practice.
SOAP in medical insurance
As regards medical insurance, SOAP note is a vital document of patient’s medical history that can be used for medical charting and is useful for the patient scheduling, hospitalization, treatment planning, billing and future reference. The other most important benefit of the SOAP note is that it is a crucial document that is used to communicate patient information and medical details with the medical departments and other medical professionals.
SOAP stands for S – Subjective, O- Objective, A- Assessment and P- Plan.
This section records the initial impression of the patient. The doctor’s records the patient’s appearance, behavior, reason for visiting the doctor and chief medical complaints. Everything that the patient narrates regarding his medical complaints can be documented in this section.
This also includes the past medical history of the patient. It is necessary to note any major medical illness, surgery, injury, allergies etc. Another important point is family history, for example any history of major illnesses, like diabetes, heart disease, hypertension, etc in the family. Any drug history, for example, any medications taken in the past, any drug allergies, etc must be noted down.
Then the most important section is the present complaints. This records the details of present complaints as narrated by the patient. Doctor often asks related questions to obtain the necessary information about the complaints. The complaints are often noted in a sequential order of onset, location, duration, nature, factors affecting it, associated symptoms and any medication taken for the same.
In this section the observations made by the doctor are noted. These include measurement of height, weight, temperature, pulse, blood pressure, etc. The outcome of clinical examination of basic systems, eliciting of reflex responses, in terms of normal findings or abnormalities found. This also records the results of tests performed on the patient like, blood tests, pregnancy tests, or similar clinical investigations.
After considering the subjective and objective components, the doctor evaluates the case and tires to draw rough conclusions as regards the possible diagnosis of the case. This can be noted as a probable diagnosis, which is most likely the disease case or differential diagnosis where a list of possible diseases in mentioned and needs to be further evaluated for confirmation.
This section records the further action plan for the patient. This could be treatment plan in the form of medications, dosage and duration or simple lifestyle modifications with diet and exercise advice. This can also be about further investigations in the form of lab tests, scans, etc in order to confirm diagnosis.