SOAP Notes & Other Note Formats. Does it really matter?

The beginning of the SOAP note format dates back to the 1970’s in an effort to standardize medical documentation. Standardization is important because it helps ensure that important elements are captured and it speeds up the process of note taking. SOAP notes can be broken up into 4 main categories.

Subjective

This should include information that the patient gives, like a “Chief Complaint.”

Objective

This is information gathered by the Provider. It includes diagnostic tests and tools.

Assessment

The Assessment portion is where the Provider interprets the information gathered from the Subjective and Objective portions and then provides a Diagnosis. 

Plan

After a Diagnosis is established, a proper plan should be developed to resolve the concern. This can include further evaluation, treatment, or referrals.

Does the format of your notes matter?

There are instances when a SOAP note should be considered, but ultimately the format does not matter. Here are some helpful tips:

1. Use SOAP notes for unplanned patient visits. If your patient has a dental emergency, you should consider using the SOAP format. For planned dental appointments the focus should be on standardization and thoroughness and less on the format.  

2. Standardize your notes. While your notes may be easy for you to read and interpret, they should be completed in a way that is easy for your staff to understand. Being consistent with formatting can definitely help. This is also important when submitting information for insurance reimbursements.

3. Include detail. Think more not less.  Take a look at our 10 Tips On Writing Excellent Treatment Notes

4. Incorporate relevant information. Whichever format you use, be sure that you’re including relevant information from the patient, your assessment, the diagnosis, and the course of action. 

5. Use available resources. Your malpractice insurance carrier may have some helpful resources. Also check with your colleagues for their best practices.

Toothnotes can also help. We not only will standardize your note taking process, but we’ll help you remember what you should consider including. There is no question, Toothnotes will save you time and your staff will thank you. Let us know how we can help you. Email us at  info@toothnotes.com.