Posted: March 6th, 2025

Writing SOAP Notes: A Guide to Effective Patient Care Documentation

A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This method ensures consistency and clarity in patient records across various healthcare settings. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.

Instructions:

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SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. This structure helps healthcare providers systematically approach patient care documentation. The episodic SOAP note is to be written using the attached template below.

For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:

S = Subjective data: Patient’s Chief Complaint (CC).

O = Objective data: Including client behavior, physical assessment, vital signs, and meds.

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A = Assessment: Diagnosis of the patient's condition. Include differential diagnosis.

P = Plan: Treatment, diagnostic testing, and follow up

This detailed breakdown ensures all critical aspects of patient interaction are captured accurately.

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Submission Instructions:

Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspellings.

You must use the template provided. Turnitin will recognize the template and not score against it.

These guidelines promote uniformity and professionalism in submission quality.

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Your submission will be reviewed for plagiarism through Turnitin.

SOAP Note RubricSOAP Note RubricCriteriaRatingsPts

"Mastering SOAP Notes: A Guide to Effective Patient Care Documentation"

References:
Weed, L. L. (1968). "Medical Records That Guide and Teach." New England Journal of Medicine, 278(11), 593-600.

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Cameron, S., & Turtle-Song, I. (2002). "Learning to Write Case Notes Using the SOAP Format." Journal of Counseling & Development, 80(3), 286-292.

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