The SOAP (Subjective, Objective, Assessment, Plan) is a form of notes for a patient and is a very important part of the medical record. A nice and detailed SOAP not only helps you to recap the case in details but also helps other clinicians to follow-up easily. There is no one way to write SOAP but following is a generalized idea on how to write a SOAP:
Subjective includes signalment, detailed history, and evaluation of the patient with non-measureable parameters. E.g. food and water intake, mentation (QAR, BAR, Depressed), defecation, urination.
Objective includes the measurable/quantitative clinical parameters of the patient. E.g. TPR, patient’s weight, physical exam and evaluation of different organs/systems. Results of all the diagnostic tests performed.
Assessment includes analysis or interpretation of your subjective and objective data. i.e. Making a problem list from the history, physical examination and diagnostic tests performed. Based on the problem list, make a list of differential diagnoses (with top to the least likely). It is best to use DAMNIT approach to make the differential diagnoses list:
D = Degenerative, Developmental
A = Anomalies, Auto-immune
M = Metabolic
N = Neoplasia / Nutritional
I = Inflammatory, Immune, Infectious, Idiopathic, Iatrogenic
T = Trauma, Toxicity
Plan includes the things to be done, e.g. treatment (injections, fluids etc. with all the details of drugs with dose, concentration, time and route of administration), diagnostics to be performed or repeated. Any minor/major surgical procedure to be performed. Parameters to be monitored. Pertinent client education/discharge instructions can be included in this section.
Summary of how to write a SOAP:
Subjective: Signalment, History, non-measureable parameters
Objective: Measureable parameters and diagnostics: TPR, PE, CBC, Chem, UA etc.
Assessment = Problem list, differential diagnoses
Plan = Further treatment and/or diagnostics, surgery if any and client education.