The SOAP format is a way for medical professionals to provide a clear, concise documentation of a client's care. It is used by a variety of providers, including doctors, nurses, EMTs and mental health providers. SOAP format is intended to examine a patient's well-being and progress from several perspectives, ultimately providing him with the best possible care.
Tell the story from the patient's perspective. Who is he? How can he best be described in his current condition?
Note the patient's primary complaint. During this step you should detail the way the patient describes himself as feeling. Don't leave anything out, as it may all be important.
List the patient's specific complaint. Did it come on suddenly or were there warning signs? Was he injured? If so, how and when? Where was he when it happened? Find out if there was anything done at the time of the injury or incident to improve or change his symptoms.
Include the patient's past medical history. This is important because one seemingly unrelated event can lead to another. If his primary complaint, for instance, is depression, a head trauma or previous bout with depression is pertinent.
List any medications he is currently taking or has just stopped taking.
Give your perspective. What was your first impression of the patient? Did he seem alert and able to answer questions? Did his story make sense to you? If you were on the scene, what was your impression of the incident?
Post an accurate accounting of his vital signs, or in the case of a mental consultation, an accounting of his current mental condition.
List anything discovered during the physical exam, if the complaint is physical in nature. If the complaint in mental in nature, make note of anything you find upon spending time with the patient.
Post any general observations you have, such as the patient's behavior, the behavior and condition of anyone who comes in with him, how he's dressed, or if he appears to be under the influence of drugs or alcohol.
Determine your conclusions based upon your initial meeting with this patient.
List your probable diagnosis and any alternatives that may have occurred to you.
Synthesize the objective and subjective information regarding the patient, keeping it brief.
Develop a plan of action. What do you believe needs to be the next step taken in his treatment?
Assist in the next step. If need be, refer him to a specialist or schedule a follow-up appointment.
Design the approach you are going to use in dealing with this patient and list why you've chosen this route.