Posted: September 22nd, 2023
Submit a Problem-Focused SOAP note
Submit a Problem-Focused SOAP note here for grading. You must use an actual patient from your clinical practicum. Review the rubric for more information on how your assignment will be graded. Be sure to use the SOAP note template for your program and view the rubric associated with your program for details on how your assignment will be graded.
Psychiatric Mental Health NP Students
PMH- NP Template: PMHNP SOAP Note TemplateDownload PMHNP SOAP Note Template
PMH-NP Grading Rubric: PMHNP SOAP Note RubricDownload PMHNP SOAP Note Rubric
Rubric
N682L-A SOAP Note Rubric
N682L-A SOAP Note Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeS (Subjective)
10 pts
Accomplished
Symptom analysis is well organized, with C/C, OLD CART, pertinent negatives, and pertinent positives. All data needed to support the diagnosis & differential are present. Is complete, concise, and relevant with no extraneous data.
Writing Effective Problem-Focused SOAP Notes
Introduction
SOAP notes are a common documentation format used in healthcare to record a patient’s medical history and share information between providers (Hughes, 2008). The SOAP format organizes a note into four main sections: Subjective, Objective, Assessment, and Plan. Of these sections, the problem-focused SOAP note places special emphasis on clearly identifying a patient’s chief complaint or problem in the Subjective section to guide clinical decision making and treatment planning. Well-written problem-focused SOAP notes are essential for effective communication, continuity of care, and quality patient outcomes. This article will discuss best practices for writing the different sections of a problem-focused SOAP note based on evidence from the literature.
Subjective Section
The Subjective section is where the patient’s chief complaint or problem is documented (Hughes, 2008). This section should concisely summarize relevant information from the patient’s history in a way that clearly identifies the main problem to be addressed. According to Taylor et al. (2016), key elements to include are:
Chief complaint (CC): A brief 1-2 sentence statement of the patient-identified problem in the patient’s own words.
History of present illness (HPI): A chronological summary of events leading up to the CC, including location, quality, severity, timing, context, modifying factors. Relevant negatives should be noted.
Review of systems (ROS): Pertinent positives and negatives related to the CC from a systems review. Extraneous details not related to the CC can be omitted.
Pertinent past medical, family, and social history: Only include histories relevant to understanding the CC.
Organizing the subjective data around the CC helps the reader quickly understand the patient’s main problem without getting lost in extraneous details (Taylor et al., 2016). Using the patient’s own words to describe the CC engages them and sets the focus for the note.
Objective Section
The Objective section documents the physical exam findings and relevant laboratory/diagnostic results pertinent to the CC (Hughes, 2008). Exam findings should be organized by body system and include both positive and negative findings. Only abnormal lab/test results directly related to evaluating the CC need be included. Irrelevant normal findings waste time and confuse the reader (Taylor et al., 2016). Objective data provides clinical evidence to consider in the assessment of the patient’s problem.
Assessment Section
In the Assessment section, the clinician analyzes the subjective and objective data to arrive at the most likely diagnosis or diagnoses related to the CC (Hughes, 2008). It is best to list diagnostic possibilities in order of decreasing likelihood when the diagnosis is uncertain (Taylor et al., 2016). The assessment considers both the patient’s main problem and important related issues or comorbidities uncovered during the history and exam. Well-supported assessments demonstrate clinical reasoning and set the stage for targeted treatment planning.
Plan Section
The Plan section outlines the treatment plan, goals, and follow up for the problems identified in the assessment (Hughes, 2008). Specific action items should include:
Diagnosis or diagnostic tests: Working/provisional diagnoses and any tests ordered to clarify diagnoses.
Treatment: Medical, surgical, rehabilitation, or referral plans. Short and long term goals stated in measurable terms.
Patient instructions: Education, medications, activity changes, follow up needs.
Follow up: Timeframe for reevaluation, pending results, subspecialty referrals (Taylor et al., 2016).
Well-defined plans demonstrate accountability and facilitate coordination of care. Including specific goals and follow up ensures the treatment plan’s effectiveness can be evaluated over time.
Conclusion
In summary, problem-focused SOAP notes provide a standardized format for clinicians to efficiently communicate a patient encounter with a focus on clearly identifying, assessing, and planning treatment for the patient’s main problem or chief complaint. Following best practices outlined here for each SOAP section supports comprehensive and coordinated patient care. With practice, healthcare providers can learn to write concise yet informative notes that optimize clinical decision making and quality of care.
References
Hughes, R. G. (2008). Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality.
Taylor, C., Lillis, C., LeMone, P., & Lynn, P. (2016). Fundamentals of nursing: The art and science of nursing care (8th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
