Reference: https://blog.gorendezvous.com/en/what-is-a-soap-note
Reference information:
Julie:
I am really unsure if relevant, but leave you with this as this is not my area of expertise: https://blog.gorendezvous.com/en/what-is-a-soap-note. In your case "S O A P I":
The SOAP, SOAPIE, or SOAPIER notes are well known in the health field, they are used by physiotherapists, chiropractors, osteopaths, massage therapists, occupational therapists, and many others. They allow professionals to enter all relevant patient information in a standardized and easy-to-read manner. This way, all health professionals will be kept informed of the patient’s condition, the various appointments, and the progress.
We start with the SOAP format, then we can add the IE and finally the R as needed:
SOAPIER
**Subjective**: This is the part where the patient’s observations are recorded. Here, we can find their symptoms, family history, old injuries, lifestyle, health history, etc. It is also possible to include the goal the patient wants to reach with the consultations.
**Objective**: Here you can find information that does not change such as biological sex, age, blood type, apparent injuries, etc.
**Analysis**: This part will contain the professional’s analysis of the data from the subjective and objective parts. This section contains the list of issues, reasoning, treatment goals, treatment direction, etc. It’s where you can do an assessment of a patient’s needs and analyze additional factors that may interfere with the treatment plan to draw conclusions.
**Plan**: Here, you can decide on the plan to adopt in order to achieve the goal set with the patient. You can indicate the duration of the treatment and its frequency, the strategies adopted, and a description of the overall treatment.
**Intervention**: It’s where you can add the interventions carried out since the beginning of the implementation of the plan. Each intervention can be mentioned in detail, it can also include the training prescribed to the patient if there is any.
**Evaluation**: This part includes the evaluation of the effectiveness of the interventions, how the patient reacts, if they see improvements, etc.
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Revision: The revision part allows you to see if you should change the plan or readjust it according to the results obtained so far.
| Taña Dalglish
Jamaica
Works in field
Native speaker of: English
PRO pts in category: 60
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peer agreement (net): +2
