Pacs-Soap Noting

Front 1

List some purposes of documentation.

Back 1

Communicates essential information to other healthcare professionals.
Permanent record of patient information & evidence of healthcare professional activities
Legal record of patient care
Back-up for billing purposes

Front 2

List some characteristics of good documentation.

Back 2

Neat
Organized
Information found quickly
Understandable
Accurate

Front 3

List some characteristics of good patient care.

Back 3

Assessment
Plan to resolve problems
Plan for future follow-up: Ensure problems are resolved/Outcomes met

Front 4

What should you do before making a SOAP note?

Back 4

Create a prioritized problem list
Check the medication list

Front 5

Problems are prioritized by?

Back 5

Patient complaint
Severity of illness

Front 6

What should you be looking for when Checking the medication list before making a SOAP note?

Back 6

Do all of the medications match up with a disease/condition?
Is there an indication for each medication?

Front 7

List the components of the Subjective portion of SOAP note.

Back 7

Chief complaint (in patient’s own words)
HPI
PMH
Medication history
Allergies
Social & family history
ROS

Front 8

Includes information given by the patient, family, and caregivers

Back 8

Subjective

Front 9

Includes data that can be measured objectively or is observed by the healthcare professional

Back 9

Objective

Front 10

List the components of the Objective portion of a SOAP note.

Back 10

Vital signs
Physical findings/physical examination
Lab results
Serum drug concentrations
Diagnostic tests
Computerized medication profile

Front 11

Critical thinking and analysis

Back 11

Assessment

Front 12

What do you do in the Assessment of a patient in SOAP?

Back 12

Determine
-Health status of the patient
-Outcomes
Look at two things:
-Disease state
-Drug therapy

Front 13

Plan

Back 13

Involves actions that were or need to be taken

Front 14

What should be Included in the Plan/SOAP?

Back 14

Should include appropriate detail without being too lengthy
Should include monitoring and follow-up
Should include patient education given

Front 15

Describe the process of creating a SOAP

Back 15

1.Read case. Look up any acronyms & terminology you do not know.
2.Create a prioritized problem list.
3.Compare the medication list to the problem list.
4.For each problem, gather the subjective & objective information.
5.For each problem, assess and develop a plan.