Nursing Practice
The SOAP
The SOAP note was first generated by Dr. Lawrence Weed, MD in the 1970’s, under the acronym POMR (‘Problem Oriented Medical Record’). At the time, there was not an objective method of documentation, which lead to physicians making unscientific decisions about patient treatment (EMR Soap, 2015).
The purpose of the SOAP note is to guide the clinician through the process of information gathering in a systematic way. It enables the clinician to make determinations on care by finding out Subjective information the ("S" of SOAP), which is the illness as interpreted by the patient; the Objective (O), which are the observations of the clinician; Assessment (A), determination of the illness through analysis of "S" and "O"; and coming up with the Plan (P) of care.
SOAP notes are key to successful practice; they are the source of information relied on in all health care settings. Good SOAP notes are the hallmark of best practice with respect to documentation, teaching, communication, planning, diagnosis, and follow-up. The SOAP promotes good communication between clinicians and facilitates the teaching/ learning process. It emphasizes adherence to a documentation style that leaves little room for potential misinterpretation (Maldonado, Zuniga, & Uzelac, 2005).
A well developed SOAP demonstrates the successful learning outcome of the nursing competency Nursing Practice. My example SOAP, attached below, reflects promotion of best practices in the advanced nursing management of health, illness and disease state with an adult-gerontology patient.
Reflective statement: The SOAP attached to this section demonstrates competency in nursing practice by means of its completeness in form and content. A proper HPI is taken, complete histories, medications, allergies, review of systems, pertinent positives/negatives, differentials, assessment, plan of care, and follow-up. These are fundamental to nursing practice; the accuracy and completeness of this SOAP note demonstrates an understanding of these fundamentals to nursing practice.
Soap notes. (2013). Retrieved from www.emrsoap.com/definitions/soap
Maldonado, D. C., Zuniga, C., & Uzelac, P. S. (2005). SOAP for family medicine (1st ed.). Baltimore, MD: Lippincott Williams & Wilkins.
The purpose of the SOAP note is to guide the clinician through the process of information gathering in a systematic way. It enables the clinician to make determinations on care by finding out Subjective information the ("S" of SOAP), which is the illness as interpreted by the patient; the Objective (O), which are the observations of the clinician; Assessment (A), determination of the illness through analysis of "S" and "O"; and coming up with the Plan (P) of care.
SOAP notes are key to successful practice; they are the source of information relied on in all health care settings. Good SOAP notes are the hallmark of best practice with respect to documentation, teaching, communication, planning, diagnosis, and follow-up. The SOAP promotes good communication between clinicians and facilitates the teaching/ learning process. It emphasizes adherence to a documentation style that leaves little room for potential misinterpretation (Maldonado, Zuniga, & Uzelac, 2005).
A well developed SOAP demonstrates the successful learning outcome of the nursing competency Nursing Practice. My example SOAP, attached below, reflects promotion of best practices in the advanced nursing management of health, illness and disease state with an adult-gerontology patient.
Reflective statement: The SOAP attached to this section demonstrates competency in nursing practice by means of its completeness in form and content. A proper HPI is taken, complete histories, medications, allergies, review of systems, pertinent positives/negatives, differentials, assessment, plan of care, and follow-up. These are fundamental to nursing practice; the accuracy and completeness of this SOAP note demonstrates an understanding of these fundamentals to nursing practice.
Soap notes. (2013). Retrieved from www.emrsoap.com/definitions/soap
Maldonado, D. C., Zuniga, C., & Uzelac, P. S. (2005). SOAP for family medicine (1st ed.). Baltimore, MD: Lippincott Williams & Wilkins.
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