SOAP notes provide evidence of patient contact and let you communicate vital information to other healthcare providers. Download them for free from the websites mentioned in this article.
For healthcare providers, physicians, and other medical professionals, burnout is a major challenge. They meet many patients every day as well as spend hours completing admin work such as charting and taking extensive patient notes.
If you’re in the medical field, you already know how complex and time-consuming the latter can be. That’s because medical records have to be documented accurately and in an organized way, so it’s easy to track patients’ progress and avoid miscommunication. For that purpose, most healthcare providers like you use SOAP notes.
SOAP notes let you record and maintain patients’ initial assessment, diagnosis, and treatment details in a standardized format, which can also be used by or shared with other healthcare providers.
If you’re new to SOAP notes, read on to learn what they are and how they can help standardize patient documentation. And if you already use them, we’ve got some free SOAP notes templates you can try. We’ve also suggested some popular medical software tools that offer built-in SOAP note templates.
What are SOAP notes and their benefits?
A subjective, objective, assessment, and plan (SOAP) note is a common documentation method used by healthcare providers to capture and record patient information, right from the intake form and diagnosis to the treatment plan and progress note. All SOAP notes have a standardized format that is divided into four categories (discussed in the next section).
By organizing patient records in a defined template, these notes help cut down manual errors and miscommunication. Each piece of information is entered into a specific field on the template, so medical providers know where exactly to find the information they need. They don’t have to go through the entire form to find the one tiny bit of information they require.
A standardized SOAP note template also makes it easier to share records with other healthcare providers, if required. Since both use the same documentation method, there’ll be no miscommunication regarding a patient’s treatment plan or health status.
4 components of a SOAP note
This covers your patient’s detailed medical history and current symptoms. Notes from your verbal interaction with patients as well as what they tell you about their condition go here. Record your patient’s chief complaint, existing symptoms, and any pain description in this section. Any comments, concerns, or questions your patients may have are also included here.
This is a record of your physical examination of the patient’s condition. It includes observations that can be measured such as body temperature, pulse rate, and blood pressure. It has details of any visible symptoms such as changed skin color or any deformities you feel when physically examining the patient. You can also include details of previous diagnostics tests (e.g., X-rays) and lab reports.
The next component of a SOAP note is assessment. It includes a summary of your diagnosis of the patient’s existing condition. For any patient, there may be one clear diagnosis or multiple issues that require separate diagnoses. There may also be cases where a definitive diagnosis is not made by the physician, therefore many possible diagnoses are included in the assessment.
The last component of a SOAP note is plan. It includes the treatment plan (e.g., medication, therapies, surgeries) you’ll follow for the patient. It may involve more tests to either confirm or rule out a diagnosis. The plan may even include details on the patient’s self-care, such as bed rest, days off work, and healthcare and lifestyle recommendations.
Free SOAP notes templates
- Examples: This website offers free SOAP notes templates for medical specialties including psychiatry, asthma, psoriasis, pediatric, and orthopedic. The templates are available in PDF format, and the file size starts from 2KB.
- SampleTemplates: This website offers free SOAP notes templates related to nursing, physical therapy, pediatric, massage, clinical progress, and more. The formats for downloading the templates are DOC and PDF, and the file size starts from 8KB.
- Teachers Pay Teachers: This website offers free SOAP notes templates for speech therapy, school counseling, school psychology, and more. The templates are available as DOCX, XLSX, and PDF files, and their size starts from 14KB.
Medical software tools with built-in SOAP notes templates
If you’re willing to invest, there are specific medical software systems that offer built-in templates. With built-in SOAP notes, all patient records you enter are directly linked to and saved on your medical software.
We’ve listed the top three software tools that have SOAP note templates. These products are selected from Capterra’s medical software-related categories and arranged alphabetically. Read our complete product selection methodology here.
Kareo is a cloud-based medical billing tool for practices of all sizes. It lets you create customized SOAP note templates, schedule appointments, verify patients’ insurance eligibility, send eClaims, manage collections, store documents online, and more.
According to user reviews, the software is easy to use and lets physicians enter the International Classification of Diseases, Tenth Revision (ICD-10) and Current Procedural Terminology (CPT) codes immediately after assessing their patients and recording their notes. Some users also find the tool inexpensive compared with other options.
Formerly known as SOAP Vault, Noterro is medical practice management software that lets you create SOAP notes right from the appointments section on your calendar. You can add tags to the notes and even duplicate completed notes to save time. Every note is stored in Noterro’s database.
Reviewers say the tool is intuitive and lets them create, store, and print SOAP notes. They also like that it combines scheduling and SOAP charting capabilities, which allows them to manage both the processes using the same software.
Practice Fusion is cloud-based EMR software that offers patient scheduling, charting, e-Prescribing, and lab integration, among other features. It lets you add patients’ past medical history and visit notes directly into the SOAP notes you create. You can edit the templates per your need and create customizable shortcuts to autopopulate patient details.
According to user reviews, Practice Fusion’s SOAP notes are easy to create and use. Users also like that they can schedule appointments, create SOAP notes, and document questions for patients and other details using the same tool.
But if you’re looking to buy new software, we suggest opting for one that offers built-in SOAP note templates. You can select from the three tools we’ve recommended or check out more options on Capterra’s software directory.
Methodology and Disclaimer
We searched medical software-related market categories such as EMR, medical billing, mental health, massage therapy, chiropractic, and medical practice management for systems offering SOAP notes templates. We made a list of highly reviewed systems (100+ reviews) and selected the top three with the highest number of reviews.
Note: The content in this piece, which provides the opinions and points of view expressed by users, doesn’t represent the views of Capterra.
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