A focused SOAP note is a written record of your encounter with a patient that only assesses those systems that pertain to the complaint. The purpose of writing episodic SOAP notes is to ensure you meet competencies related to gathering problem-specific health histories and synthesizing physical examination data needed to formulate a plan of care. Through this assignment, you will gain experience in formulating a plan based upon specific patient information and communicating the plan in a clear and organized manner.
When completing your SOAP note:
Remember cultural competence! Avoid stereotyping an individual based on age, gender, sexual orientation, ethnicity, socioeconomic status, religion, or behaviors. Care should be taken to assess family, social, cultural beliefs that may impact health beliefs and practices. For individuals with language barriers, an interpreter should be available for best practice.
The SOAP Note Tool is a step-by-step form that you can fill out to easily draft your SOAP note. Some fields will have an “i” icon next to them. Hovering over the “i” icon will provide critical information for filling out that field. When you complete the SOAP note, you will have the ability to save it as a Word document. Be sure to review your SOAP note and make any necessary edits before submitting your assignment in Canvas.
Click on the button below to access the SOAP Note Tool.
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