How SOAP Notes Reduce Patient Risk
Paperwork is often credited with causing headaches, not reducing harm or actually helping anyone.
So, while it might seem counterintuitive to connect medical documentation to increased patient outcomes, SOAP notes are a standalone example of how that connection is real. This type of medical documentation–short for Subjective, Objective, Assessment, and Plan–is an essential component of any healthcare practice, whether traditional or holistic.
In this article, we’ll dive into what exactly are SOAP notes, how they help reduce patient risk and result in better patient outcomes, plus why they’re important for medical billing. Keep reading to learn more!
What are SOAP Notes?
This form of healthcare documentation is the standard formula for compiling a comprehensive report of your patient’s experience and charting a course forward with a treatment plan that can help their ailments.
Let’s dive into each letter of this fun acronym:
S = Subjective
This first component of SOAP notes involves noting the subjective experience of your patient from an array of perspectives, including their feelings, perceptions, and personal opinions in relation to their condition.
The Subjective section of SOAP notes captures how the patient is feeling, thinking, and experiencing their ailments in their own words. This is a great start to the dialogue between patient and provider because the healthcare practitioner can gain an understanding of how the patient is doing.
Outlining this section of SOAP notes might vary from practice to practice, specialty to specialty. For example, if you were performing an initial consultation for someone seeking acupuncture services, you might ask the following:
- Rate the severity of pain on a scale of 1 to 10
- Describe the feeling of the pain (is it shooting, throbbing, dull, aching, etc.)
- Note the places of pain on the body
- Describe when the pain started and how it might change during the day
- Ask how the patient feels about needles
O = Objective
Once you’ve established the subjective views of the patient, it’s time to acquire the objective aspects of their condition. This might include:
- Allergies
- Body posture
- Range of motion
- Imaging results
- Medical diagnoses
- And more!
Each notation in this section should be factual and able to be proven; in other words, be sure to filter out assumptions or subjective language in this section.
A = Assessment
When you combine the information of the subjective and objective experience of the patient, you can conduct an assessment to determine what might be ailing your patient. If there might be a handful of causes, then be sure to list what you hypothesize your patient is dealing with ranging from most to least severe or important.
This section is vital for outlining your thought process and explaining how you arrived at your conclusions. Not only is this important for leaving a paper trail for your own knowledge, but it’s also incredibly helpful for other providers to refer to when treating your patient from other perspectives, such as conventional medicine providers.
P = Plan
Now that you’ve gathered the subjective, objective, and assessment components of your medical documentation, you’ve reached the final step: creating a plan. This might include noting:
- Which follow-up appointments are necessary and with whom
- Referrals to other providers or specialists
- Referrals for further testing or diagnostic services
- Therapy
Be sure to include all relevant information that the patient will need to follow through with your treatment plan and maintain an open line of communication with them after you provide your services.
How Do SOAP Notes Reduce Patient Risk?
The purpose of SOAP notes is multifold–they are essential for leaving a paper trail for medical billing reasons, they help you and other providers document a patient’s condition, and they reduce patient risk. How does paperwork lead to better patient outcomes?
Comprehensively analyzing your patient’s pain points, whether literal, metaphorical, or perceived, means that you’re taking the time to be thorough. Looking at something from multiple angles or considering a wide range of factors means that something is less likely to slip through the cracks or be ignored.
This means that you’re being vigilant in your interaction with the patient and valuing their input as much as the objective facts or other providers’ interpretations. Recognizing the role that your patient plays in their own treatment plan is essential for keeping them engaged, continuing an open dialogue in the patient-provider relationship, and overall reducing their risk.
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