SOAPIE Charting for Stronger Patient Care Documentation

By Indeed Editorial Team

Published June 10, 2022

The Indeed Editorial Team comprises a diverse and talented team of writers, researchers and subject matter experts equipped with Indeed's data and insights to deliver useful tips to help guide your career journey.

Documentation is a crucial aspect of patient care because it provides healthcare professionals with important information about a patient's past and current medical status. Preparing optimal patient progress notes that include relevant details requires specialized knowledge and practice. A standardized documentation framework like SOAPIE charting can help care providers write comprehensive and organized progress notes that support high-quality patient care. In this article, we discuss this tool, highlight when to use it, provide information on how and who can make one, and give tips to help create an effective SOAPIE chart.

What is SOAPIE charting?

SOAPIE charting is a comprehensive framework for collecting and organizing patient information that addresses the patient's experience and technical details about treatment. SOAPIE is an acronym that describes each section of the chart: subjective, objective, assessment, plan, implementation, and evaluation. The areas in a SOAPIE chart address different perspectives and types of information that may influence a patient's treatment or provide additional context for future healthcare providers. Because SOAPIE notes collect both qualitative and quantitative information about a patient's treatment, you can use them to provide a detailed record of their progress during each appointment.

How to write a SOAPIE note

Using SOAPIE helps you prepare progress notes that are clear, thorough, useful, and easy to understand. Follow these steps to structure your SOAPIE charting and document each component of a patient's care:

1. Summarize subjective information

Record subjective information about the patient's experience in the first section of the SOAPIE chart. Subjective data includes anything the patient or family tells you, including pain level, symptoms, family medical history, feelings, or concerns. You may also have your observations about a patient's behaviour, such as tone of voice or body language. Collecting subjective details can make it easier to understand how patients feel about their treatment or understand situational factors that influence their health.

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2. List objective data

Next, use the objective section to share factual information about the patient's health. This includes vital signs, test results, medications, and observations. Write down your comments about any symptoms in the objective section to provide additional context to the subjective data in the first section. For example, you may write that a patient reports itchy skin in the subjective section, then explain that you see a bumpy, red rash in the objective area. It also helps to include specific values for objective data, such as blood pressure or heart rate.

3. Complete a patient assessment

After you've collected subjective and objective data, you can use the assessment section to make a clinical judgement about the patient's health. This includes creating a diagnosis, prognosis, or treatment recommendations. The assessment section is also an excellent place to reflect on how the patient's condition has changed since their last visit. Use subjective and objective information to develop a logical conclusion about the cause of their symptoms. If there are multiple diagnoses, list each one and explain why they may apply to the patient.

4. Outline the treatment plan

The treatment plan section includes the treatment goals and the specific interventions to help the patient. When developing a treatment plan, consider the patient's preferences, the severity of their symptoms, and your assessment of the underlying cause of their condition. The care plan may explain lifestyle changes, medications, referrals, or additional tests to learn more about the diagnosis. Describe the schedule or deadline for completing each step of treatment so that you can track the patient's progress.

5. Describe healthcare interventions

The implementation or intervention section explains your actions to support the patient's health. For example, it might include similar details as the plan section if you followed your initial strategy closely or describe different measures if you changed the plan to meet growing patient needs. If applicable, explain why you chose additional steps from the initial plan. When collaborating with other healthcare professionals to administer treatment, explain who completed each action and when the interaction occurred.

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6. Evaluate the interaction

Finally, use the evaluation step to describe the results of your healthcare interventions. Outline how each action affected the patient or changed their symptoms. Use test results and professional observations to provide evidence of these outcomes. Explain which parts of the care plan had positive results, list any ineffective treatments, and offer alternative interventions to consider during the next appointment. You can also reflect on what you learned during the patient interaction and how it applies to future ones.

When to use SOAPIE charts

SOAPIE charting is a versatile tool, and you can use it in a variety of settings, including:

Collecting data during a patient interview or exam

You can quickly document what a patient says and observes during an interview with SOAPIE charts. This information can help support your diagnosis and treatment decisions. It is helpful to use this charting if you plan to refer the patient to another healthcare professional, as it provides context for their condition.

Communicating with other healthcare professionals

This charting is also a valuable tool for communicating with other healthcare professionals. For example, you can use SOAPIE charts to document a patient's condition and share your assessment with colleagues. This can help ensure that everyone involved in the patient's care agrees.

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Tracking a patient's progress over time

If you see a patient regularly, this charting can help you track their progress. Reviewing past SOAPIE charts can help you identify patterns in a patient's condition and monitor their response to treatment. It can also help you identify any potential red flags that may require further follow-up.

Preparing for patient appointments

You can use this charting to plan for patient visits by organizing your thoughts about their symptoms and health history. This information can help you ask the right questions and provide more personalized care. It also enables you to avoid duplicate testing or unnecessary treatments.

Reflecting on your practice

SOAPIE charts can help you reflect on your clinical practice by identifying areas where you made positive changes through in-patient care. After each interaction, you can review your SOAPIE chart and reflect on what went well and what you may improve. This information can help you identify areas for growth in your practice.

Who can write SOAPIE charts?

SOAPIE charting is a tool that healthcare professionals can use, including doctors, mental health counsellors, physical therapists, and nurses. Medical students and residents can use this charting to document patient encounters and prepare for case presentations. Physicians can use it to communicate with colleagues and ensure that they collaborate toward a patient's overall recovery goals. Nurses and other allied health professionals can document patient symptoms and track their progress. While many healthcare professionals use these charts, it is significant for nurses because of their frequent, ongoing interactions with patients.

Tips to make a good SOAPIE chart

This charting is a helpful tool for documenting patient interactions, but there are a few things to keep in mind to get the most out of it. Here are some tips to make SOAPIE charting more effective:

  • Review identifying information. Make sure you have the correct patient information before starting. This includes their name, age, gender, and medical history.

  • Ask clarifying questions. If you're unsure about something, ask the patient for clarification. This can help ensure that you have accurate information.

  • Be concise. The SOAPIE chart is quick and straightforward to document patient information. Avoid writing long, detailed descriptions.

  • Add dates and times. When possible, include the date and time of each action in your SOAPIE chart. This information can be helpful when reviewing a patient's progress, as it provides continuity in their records.

  • Use neutral language. Avoid judgemental or inflammatory language in your SOAPIE chart. Stick to objective facts and refrain from including your personal opinions to uphold professionalism.

  • Include all relevant details. Document all relevant information about the patient's condition, including symptoms, medications, and any other treatments they're receiving.

  • Write about your interactions with patients. While this charting is primarily about the patient, it's also helpful to document your actions and thoughts. This information can help you reflect on your clinical practice and identify areas for improvement.

  • Write neat, legible notes. This charting is easy to read and understand, so you can write neatly with consistent spacing to improve readability. Avoid abbreviations to reduce confusion.

  • Be careful when charting multiple people. If you're charting for numerous patients, avoid mixing up their information. This can help you not commit errors in their care.

  • Only use standard abbreviations. When abbreviating, only use standard abbreviations that are widely understood. This reduces confusion and helps ensure accuracy in the patient's records.

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