SOAP Notes with Body Templates

When a patient is admitted to the hospital, it is the duty of concerned doctors and para-medical staff to keep examining the patient to know his current status. We want to know the health status of the patient and ideally, he is examined in every shift.

What kind of examination is required depends upon where he is admitted and for what reasons. All the relevant systemic and general physical examination is done every 8 to 10 hours. If anything noticeable is identified, it is reported and treated immediately. So, the purpose of the examination is an effective treatment and prompt patient care.

What is SOAP???

Soap is basically an acronym that is used while examining the patient, especially in the inpatient department. It includes;

  • Subject
  • Objective
  • Assessment
  • Plan

We will discuss them one by one.

  • Subjective

In the examination of the patient, the presenting complaints are mentioned in the subjective portion of the soap note. For example, if a patient in surgery is examined on the next day of surgery, he may complain of indigestion, constipation, excessive pain, and nausea, etc. So, all such complaints are mentioned in the subjective portion.

  • Objective

General and specific examination done by the doctor is written in the objective. We can write vitals and systemic examination and if any significant finding is observed we mention it in the objective.

  • Assessment

In the assessment, we document the overall condition of the patient or diagnosis of the patient. For example, gastroenteritis, hyperemesis, etc. are written under the heading of assessment.

  • Plan

The final strategy and management plan is written under the heading of the plan.

SOAP form with body

This specific soap form with the body is for the muscular examination of the patient.

  • The name of the patient and date is written on the top of the form as also the name of the company where the examination is being held.
  • Then there is a long list of names of muscles that have to be examined under the protocol of SOAP as discussed in the above lines.
  • Starting from the skull muscles, the normal function and tone of the skull muscles are checked for example occipitofrontalis which is examined by asking the patient to frown and make horizontal wrinkles on the forehead.
  • Then there is a group of muscles that join the upper body with the trunk and are called muscles of the shoulder girdle. These muscles are checked by telling the patient to perform certain functions.
  • Muscles of the trunk and abdomen are also tested by their specific tests.
  • Muscles of the thigh like tensor fascia late, Rectus femoris, and gluteus muscles of the hip are tested by performing the normal functions at specific joints.
  • Similarly, the muscles of the upper and lower limb are tested.
  • The entire muscle group is tested for tone and function and their power is checked at every level.
  • This soap form is specifically for neurological examination if the patient has come and complained about weakness or numbness at any level.
SOAP Note Template
SOAP Note Template
SOAP Note Template

Simi Karton

Dr. Simi Karton currently resides in Los Angeles with her husband. This website is a voluntary work of Dr. Karton to provide people with useful health-related information with a straightforward approach.

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