Using the soap format in English for medical purposes

Autor: Andrés Novo Rosas y Cecilia Valdés Menéndez

Assistant Professors in "Dr. Salvador Allende" Faculty at Havana Medical University.
Havana City, Cuba

 

 

Introduction.

One of the main objectives of teaching English for Medical Purposes (EMP) is that of providing tools to understand and use authentic documents used in real professional settings. This includes not only the standard documentation (patient's charts, lab orders, prescriptions, etc.), but also the formats and methods of employing them. One such format is the SOAP; an acronym for a specific style of documentation that is often referred to as "Problem-oriented Record".
SOAP is the brief, clear, communication of the complaint, physical exam with pertinent positives and negatives, evaluation of the data, assessment and clinical plan; commonly stated in short notes containing abbreviations and symbols standard to all English-speaking countries.
Why have we used it in our English lessons?

First of all, it is the most widely used format in most countries where English is spoken, so our students may benefit by knowing how to use it, not only with the view of future medical collaboration, but also the understanding of articles and cases published in several magazines and Internet sites. Secondly, it helps to develop thought processes and study skills (such as listening, asking questions, taking down notes, stating points of view, summarizing using data appropriately, and recording results). And thirdly, it allows to integrate the four skills of the language (listening, speaking, reading and writing).
Our students have been able to use this format in EMP activities carried out in our faculty like training on the job (where the students can be asked to interview a patient, take down notes and come up with their tentative diagnoses and management plans), simulations (as in doctor-patient interviews), case presentations, and review lessons.
We would also like you to know that the SOAP format is not the only type of medical documentation there is. There are other several methods used and sometimes modified by many institutions to meet their specific needs.
One such method is the so-called narrative which is just the same SOAP information, but written in paragraph form (no notes are allowed). Another type is T.R.P. which stands for Treatment, Response, and Plan. This one is said to be used less frequently.
Another popular method is P.O.M.R., an acronym for Problem Oriented Medical Record. This one emphasizes on the problems of the patient and the SOAP format was initially part of it.
And finally, the fastest way to take down a medical history is by means of the key word SAMPLE PQRST. This stands for Symptoms, Allergies, Medicine taken, Past history of similar events, Last meal, Events leading up to illness or injury; Provocation, Position, Quality, Radiation, Severity, Symptoms, Timing, Triggering factors.

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Development.

Soap Format Components

So if you are interested in learning a little more about the SOAP format, here we include its components according to what each letter stands for. The letters in the acronym SOAP stand for Subjective, Objective, Assessment and Plan. Sometimes the letters ER are added (SOAPER) to include patient Education and Referral and/or consultations.

  • Subjetive: This section includes what the patient tells you.
  1. Chief complaint (CC)- The patient's reason for coming to see you, usually summarized in one sentence. E.g.. CC: pt. c/o generalized aches and pains.
  2. Associated symptoms- E.g.. coughing, fever, swollen glands, weakness, etc.
  3. Duration of symptoms- E.g.. 3/7 (for three days ).
  4. Any new symptoms which have appeared or prior symptoms noted- E.g.. headaches 4/7 associated with vomiting.
  5. Anything that makes the symptoms better or worse, aggravates or relieves the problem- E.g.. lying down for a while relieves the headaches.
  6. Frequency of symptoms- E.g.. daily headaches.
  7. Medications already taken- E.g.. aspirin, acetaminophen, etc - state if they were effective or ineffective.
  8. Antecedent events (also known as precipitating events)- E.g.. went camping a week ago.
  9. Severity of symptoms- rate pain as to severity and quality. E.g.. severe and throbbing headaches.
  10. Location of symptoms- E.g.. bilateral headaches, also pain in the joints and muscles.
  11. Significant negatives- E.g.. no neck stiffness.
  12. Medications currently taken- E.g.. takes an aspirin a day.
  13. Allergies- the ones known by the patient, also the effect it caused.
  14. Immunization- E.g.. ask for the patient's vaccination record.
  15. Past medical history- E.g.. surgeries, hospitalizations, history of certain diseases, etc.
  16. Diet and Appetite.
  • Objetive: This section includes the measurable and pertinent findings obtained from the physical examination and the diagnostic tests or procedures.
  1. Physical Examination- Inspection, palpation, percussion, auscultation. Includes vital signs and the review of systems.
  2. Diagnostic procedures- E.g.. lumbar puncture
  3. Diagnostic tests - E.g.. laboratory tests (CBC, blood culture), X-rays, etc.
  • Assessment: This one includes a short tentative diagnosis based on the information obtained in the subjective and objective sections.
  1. Brief tentative diagnoses for each relevant problem.
  2. Analysis of differential diagnoses.
  3. Management options
  4. Treatment (with different choices).
  5. Potential complications.
  • Plan: This component shows your decision-making.
  1. Treatment plans (medications given, change in medications, treatment prescribed specifying dosage, etc.)
  2. Further diagnostic tests which might be needed. Also include follow-up tests.
  3. Decision to perform surgical procedures.
  4. Patient education (explanation about the problem he/she has, self-care, understanding of the treatment to follow, etc.)
  5. Referrals/ Follow-up appointments.

Formats at a glance
As you have probably noticed the SOAP format includes the same elements you deal with in your daily lessons, only that their arrangement is different. We include a comparison of the Classical Medical Format (similar to the one used in our country) and the SOAP Format to give a better idea.

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Conclusions

Why do we advise you to use soap format?
There are several reasons for this. The Classical Medical Format takes a long time to fill out because it doesn't allow the use of medical abbreviations and symbols, which are widely used in English-speaking countries, so you might end up losing your motivation. . On the other hand, the SOAP format is general, so it mostly includes all the pertinent information that reflects your decision-making process, so your classmates and/or professors, just by looking at the specific headings, can quickly find the information of interest without having to search through your whole notes. It is also more reflective of your thought processes, clinical reasoning, and decision making.

Examples of soap notes:
These notes were taken by a fifth-year student during a ward round.

Subjective:
John Smith/42/ M/M/ mechanic c/o chest pain described as "oppressive feeling" in the chest. Pain was associated with dizziness, sweating and anxiety. It started unexpectedly this p.m.
PMH: MI 5 yrs ago.
FH: father died of CVA at 52.
Pt. admits heavy drinking.
Objective:
O/E pt. in pain and v. anxious.
CVS: arrhythmic HS. BP 210/140. Rest of exam N.A.D.
CBC normal; fasting BS normal; CPK and transaminases ­; EKG showed atrial fibrillation and changes suggestive of AMI.

Assessment:
Diagnosis: MI due to clinical features, increase of enzymes and EKG changes.
D.D. pulmonary thromboembolism, pericarditis, osteochondritis, esophageal rupture.
Immediate management: transfer to pre-coronary care unit. IV nitroglycerine, adenosine, heparin, and morphine. Check vital signs every three hours.

Plan:
After initial symptoms are controlled, transfer pt. to ICU. Reassessment by ICU specialists.

So, why don't you give the SOAP format a try? We encourage you to use in your next in-service training activity . If you or your teacher have any questions about this format, feel free to contact us. We will be glad to help you.
We are looking forward to receiving your comments.

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Bibliography.

Jordan, R.R., English for Academic Purposes, Cambridge Unviversity Press, 1997.

We advise you to visit these medical sites to learn more about the SOAP format:

http://mediswww.meds.cwru.edu/
http://www.vnh.org//SickcallScreeners/SOAPNotes.html
http://w3.uokhsc.edu/rehab_sciences/th&app/soap.htm
http://www.ltc.tec.oh.us/PTA101
http://www.aafp.org/fpm/20000300/29docu.html
http://www.aafp.org/fpm/980400fm/lead.html#2

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Última actualización: 16 de Mayo del 2002
Copyright © 2001 Facultad de Ciencias Médicas "Cmdte. Manuel Fajardo"
cev2002@infomed.sld.cu
 
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