My experience sharing(1) : SOAP technique and continuity care
I have learnt about "SOAP" technique for 15 years ago when I was a medical student in Chiangmai University. At the first time we visited the patient, we took a long pattern document to write about patients admission and the next other day we used "SOAP" to progress information about patient.
In 2001, Bantak hospital, that I was a director, had to be accredited the HA standard of quality care by The Institution of Hospital Accreditation and Improvement of Thailand. The main concept of Hospital accreditation (HA) is patient centered care and patient safety. The one of important values of patient centered care is patient continuity care. The external auditor or surveyor will look for the evidences of continuity care and the SOAP technique can help us for this aim.
In wards, doctors and multidisciplinary team had to write SOAP into "progress note" on the document of doctor order. It helped each profession to take care of patients and communicate with interdisciplinary profession or give data about patient care in each professional dimensions, so it's called as multidsiciplinary team for patient care, and it make to the goal of Holistic and continuity care.
SOAP technique is art and science that consists of 4 elements;
S = Subjective data: doctor or health care worker should gather an entire data by history taking from patient, relative telling or other whom see or stay with patient, so the communication skills are very important. The symptoms and the 4 dimensions of illness as "IFEE" (Idea, Feeling, Effects on function, Expectation)should completely collected from patient.
O = Objective data: We should completely collect the signs from patient. It needs our expert that called professional skills as observation and physical examination, so doctor should have eagle's eyes (good vision or prudent), lion's heart (good in decision making), woman's hand (soft, gentle).
A= Assessment: to collect entire data of patient in bio-spycho-social aspects, analise them, synthetize them for differential diagnosis, provisional diagnosis or definite (final) diagnosis.
P = Planning: this is to take a decision making for management or managing patient as following;
- planning for diagnosis: further laboratory investigation to find or support final diagnosis.
- planning for treatment: symptomatic treatment, supportive treatment, definite treatment (medical, surgical, radiotherapy, physiotherapy,...)
- planning for nursing, rehabilitation, prevention, health promotion & education
- planning for discharge: we should make a discharge planning and tell patient or relatives to know about diagnosis, timing in treatment/admission.
- planning for follow-up: what, when, where, why, how, by whom this for the next visit for continuity care (chronological, geographical, interdisciplinary, interpersonal).
So, SOAP technique is a simple and useful technique applied in patient centered care.
Enjoy to share with you (give & take, care & share, share & learn)
" I do not want you to be only a doctor, but I also want you to be a man"
by Prince Mahidol "The father of Modern Medicine of Thailand"
Phichet Banyati
November 18, 2007.
Verbondstraat52, Antwerp, Belgium.
ความเห็น (2)
Dear Red-plate,
I think so, every profession who take care of patient should apply "SOAP" technique in their practice. I mean that health care workers are doctors, nurses, medical officers, or profession in multidisciplinary team. Thank you very much for your sharing.