SOAP NOTES

Jessica Nishikawa discusses the structure and function of the SOAP Note for medical notes. Subscribe / jessicanishikawa
Follow Twitter @JessNishi

[@danitajaundoo5459]

This is exactly what I was searching for, for two whole days. Thank you so much, very clear explanation.

[@yolandarivas7544]

Thank you for sharing a simple and valued way to remember soap!

[@rico4379]

Same🙏

[@caseyburt9569]

OLDCARTS O- Onset when did the issue arise L- location of the pain D- Duration how long has the pain been going on for C- Characteristics is it throbbing, radiating, piercing pain A- Aggrevates what makes the pain worse R- Relieves what takes away the pain or lightens the pain T- Treatments have you taken any medications for the pain or issue S- Scale of 0 to 10 0 being no pain 10 being the worst pain imaginable what number do you fall in

[@stefainepatricio9559]

Is this during the S or the P ?

[@Fluxxxx]

SOCRATES

[@caseyburt9569]

@@stefainepatricio9559 It would be subjective, as it is the patient telling you. You wouldn't be able to determine any of these, thus meaning it wouldn't be objective. Subjective, as well as objective, allows you to come up with a plan.

[@yourkdrama-blfan1706]

This helps a lot on the HPI. Big thanks.

[@MoLeaveBrainstainzz]

This video was posted 4 years ago, here I am today, 4 years later Thanking you tremendously for, doing the Lords work🙌🏽🙌🏽 😂😂(No seriously) I’ve been reading, researching, & pondering my blood pressure for an entire week trying to find an explanation of documentation In layman’s terms of S.O.A.P notes!! Thank you! thank you thank you!

[@JessicaNishikawa]

You are welcome :) I'm glad you find it helpful!

[@celizabeth1220]

THANK YOU!!! My textbook doesn't explain the SOAP method very well and this saved me for my exams in two days!

[@JessicaNishikawa]

Glad you found it helpful and I hope your exam went well!

[@adimaca2359]

Thank you so much for for this I’ve been searching for this for a very longtime and you’ve got the best version of it 👏 Now I know how to write soap notes.

[@NLKEquestrian]

Extremely helpful, thank you! I really needed to see how to write one of these quickly for my next OSCE!

[@JessicaNishikawa]

Thanks for watching, good luck with your OSCE!

[@Cass_i]

Thank you. This really sums it all up plus the example made it a lot more concrete for me. This was the best.

[@malugarib1221]

Thank you, Jessica. Very useful and easy to understand.

[@BritAlaina89]

Thank you Jessica!!! This was right on time and very thorough!!

[@fernanar1]

omg You are the best. I love the video and how simple you make everything look and sound. I am currently at Fort Sam and have to go through this in order to be a Navy Corpsman and this part is the only thing that sounded confusing UNTIL now lol thanks again

[@pfcaraujo]

Amy thanks for what you do Doc!

[@lamisingh7601]

Hey Jessica, this is Lami here.. I wanna tell u that I am very much impressed by your videos.. please keep updating this channel with more n more videos. These are really helpful, am looking forward for more informative uploads from you. THANKYOU n keep up the great work ! Regards! :)

[@martinamulbah8013]

Your soap notes is the best 🙂

[@learnpharmacywiththepharma7094]

I can't thank you enough for this video like i was literally searching for a video that includes how to exactly write a case based soap note and i finally found this video. Thank you so much❤️

[@JessicaNishikawa]

SOAP notes aren't as hard as they are made out to be. Hope this simplified it a bit.

[@boscomoons7742]

Honestly, the video precisely informative. Thanks a million!

[@JessicaNishikawa]

Glad it was helpful!

[@jenniferhinson5628]

At the end of this video you mention going into more detail for the NP students. Can you post the link for that video? I love your lectures! So easy to follow yet thorough!

[@mobosh9454]

It's very very good. Thank you for your awesome video. 👌👌👌👌🔥🔥🔥🔥

[@daxcorrigall386]

Thank you Jessica you're a good teacher. This helped me a lot. I wonder if you'd want to know about spelling corrections you could do ... likely, and chief. Anyhow, I really got lots out of this video about SOAP so thank you so much.

[@JessicaNishikawa]

I know darn it :) It's way too much work to redo it though. I wish it had a spell check feature like everything else in life :)

[@dhritimansen3307]

love love love the handwriting AND information obvs

[@boscoechon7036]

Thanks a million yo work really makes my day brighter

[@irvinmanzanares7275]

I liked this video because is very interesting and now I know to make a SOAP note.

[@Nuf1av0r]

Thank you! This helped me pass my NHA exam :)

[@preparedmindstrongspirit5724]

Thanks for the video! It is really helping me to get my head back in the med game after a long absence.

[@JessicaNishikawa]

Thanks for watching, and I'm glad you're back in the game! :)

[@rpsingh18]

Very Helpful! Thank you for creating this!

[@esel7162]

Jessica you the greatest for this

[@hoangdoan642]

Very useful! Thank you so much 😍

[@rubenyero1508]

I’m currently in EMT school and we need to write two soap reports per ride time and this video was a really helpful breakdown 👍

[@JessicaNishikawa]

Glad it was helpful!

[@kristasmith4157]

I don't know if you ever read these reviews anymore, but I met you in 2009 right after you had your daughter. I am currently in school for nursing and I saw your name and I thought...WOW, what are the odds! Hope this note finds you well :) This was a super helpful video btw

[@beatricekasamba]

Thanks dear it was helpful I really needed this

[@mimishive]

OPQRSTUV O- onset when did this start P- palliative what makes it better or worse Q- quality describe the pain, stabbing or throbbing? R- region where is it located S- severity rate your pain in a 0-10 scale T- timing and treatment at what time of the day is your pain worse, are you currently taking any treatment? U- understanding what do you think caused your pain? What do you understand about it? V- value how would you like to feel after this assessment

[@simonebuhner74]

Clear, concise and very helpful, thank you!

[@crisjeturian56]

I love it, very informative! I love it and you..

[@sehrishrafeeque5919]

It's really worth watching it... Thank U soo much for sharing it in such an amazing way.. It helped me :)

[@kristiheiser5012]

Great explanation of SOAP, thanks!

[@JessicaNishikawa]

+Kristi Heiser Thanks for watching!

[@wengthoughts]

thank u. I'll be having an exam soon regarding this.

[@robertkaranja3113]

Jessica Nishikawa you are awesome

[@xxsnow_angelxx3953]

so easily!! i love the art

[@vannsylten6765]

This was incredibly helpful! Thanks for being straight and to the point!

[@MrsCoach1999]

Love your videos! May I share with my students?

[@JessicaNishikawa]

Of course :)

[@SFL3G]

Thank you for all the great content

[@martinamulbah8013]

This is what I was looking for too

[@greenlove4572]

Can you help me with my sports med hw. Lol 😂

[@NarrowRoad7]

Thank you for sharing this with us. I got the full understanding:)

[@pournimashrikhande4137]

Very well explained

[@JessicaNishikawa]

Glad it was helpful!

[@elasion4384]

Thank you, this was very helpful.

[@mrs.mckeller1483]

Thank you soooooo much you have made it so east for me to understand!!

[@camiblutube7116]

Love this! Could you please do a PES Statement? Thank you!

[@chibuikemnnamdi6143]

Nice. I just need questions to practice with

[@diyamajumder2711]

Thank you very much this video very helpful for me

[@ghousiahealthcarekarachi4541]

Good knowledge 👍😉

[@natinuella5836]

Wow just what needed Thank you

[@AaronmBenton1]

Great info. Very simple

[@FonzoScat-rl6nq]

Thank for the info

[@JessicaNishikawa]

No problem!

[@sharongonzales2495]

SOOO HELPFUL 🥰

[@nyenye5292]

Perfect 🤩 thanks a bunch

[@TarekYahia-v2j]

Thank u ❤

[@joypauline3236]

I was really having a hard time getting my Soap note last week😓😓 but I’m all good and that’s #Cybercredible# work 👍

[@markrobiso]

Another example using the Practice Fusion platform, please. Thank you!

[@pradeeppati7932]

thank you mam. it is clear and simple to understand.nice video.

[@maggvmay]

Subjective: chief, complaint, History of present illness, past medical history, family history, social history, review of systems, objective: vital signs, general survey, genes, lymph, chest, CV, abdominal ect Assent: global assessment of patient including differential diagnosis. In order from most likely to least likely Plan: diagnostic tests that will be ordered drugs of treatments that will be prescribed Patient education follow up

[@kristencrane2872]

I am guessing that an RN SOAP note would be different as far as the assessment part goes since nurses don't diagnose. In this case would a nursing diagnoses be part of the assessment?

[@valeriewinnie]

You are correct! as an RN you would use nursing diagnosis. In the case of the sore throat, for example, you could use "impaired comfort r/t sore throat" or "impaired oral mucous membrane r/t inflammation or infection of oral cavity", etc.

[@claytongrey988]

@@valeriewinnie thanks for that! I was about to ask the same question.

[@big4020]

Awesome clarification. Thank you

[@audzlongaza9397]

Thank you for this. I learned a lot.

[@elizabethpierce3647]

Hi Jess! I love your videos! Thank you for putting the time and effort into them. Question:is this the video for the FNP students? You had mentioned that a more detailed/expansive video would be coming that was meant for FNP students. Is this the one? Thanks much!

[@JessicaNishikawa]

Hi Elizabeth... I think I had intentions to do another video, but never got around to it. My 'to do' list got away from me for the last several years :) Thanks for watching. If you subscribe then you'll be notified when more videos are published. Aloha- J

[@libbypierce3941]

Jessica Nishikawa , I'm wondering your opinion on an educational phenomena. There are a plethora of online FNP programs now, turning out literally thousands of new FNPs. How do you recommend FNP students develop that mastery of physical exam skills, when in an online program (in which all content is in a distance learning environment, except for clinical hours w/preceptor). How can the online student develop PE proficiency, BEFORE their clinical time under a preceptor? Ideas? Want to start a "Hawaii Boot Camp" for FNP students?!?! 😉

[@JessicaNishikawa]

Hi Libby, if you are in a FULLY online program it can be challenging! You can try virtual patient experiences (iHuman or others), they will help develop clinical reasoning but not much actual physical examination techniques. You should also examine as many of your friends and family members as you can - until they're sick of you :) It will help a lot. Is there an NP school near you? You could try to get in on their study sessions. Wish you the best!

[@eightysixoneeightysix3184]

very useful. thankieeee --- bsoa student

[@MrPedrojose1967]

Very interesting to use as a Telephone Triage Nurse.

[@sultanshorbaji1988]

Thank u very much The video is really helpful

[@kanantalukder557]

Thanks❤️❤️

[@nidarajpot8250]

Kindly make vedio on CORE pharmacotherapy plan and PRIME AND FARM note

[@ShireenFatimaANBZ]

helpful 👍

[@julieadrian1422]

I see ROS is listed under subjective, should the ROS be under objective heading as this is an examination?

[@glowilk5377]

Spelling counts in documentation 👍

[@benjaminmanzano9284]

thank you for sharing with us

[@Gymnopediea]

I'm not sure if this is such a big deal but I've been taught to never write "denies HA, Rhinitis, etc" and instead to write "reports absence of HA, Rhinitis, etc"

[@farahwakil9479]

Very nice thanks dr

[@asma16cool]

Thank you!

[@rebeccadavies1687]

Hello :) Just a quick question. What does it mean when it says 'billed for'? Thank you

[@JessicaNishikawa]

Hi Rebecca, Sorry I am getting to this message late. "Billed for" refers to the medical diagnoses that get submitted to insurance companies to support the billing for a patient encounter. As a medical provider in the United States you have to code your visits and then submit support for that code. Thanks for watching.

[@reesejackson1984]

Define and List subjective data in pain assessment. Chief complaint history of present illness past medical history social history 2. Define and List objective data in pain assessment. Record physical findings vital signs general survey gent lymph 3. List 10 possible causes of discomfort. 4. List several methods for pain control.

[@harelljuanico4293]

Thanks for the video! Very helpful! May I ask a question? Do doctors always take the patient's review of systems, family history, social history etc. every consultation? Wouldn't it be redundant? Or do they keep a record of it? Awesome video!

[@jessnishikawanursing570]

Hi Harell Juanico, thanks for watching! To some degree clinicians ask these questions on most patient encounters. Usually we keep it focused and only ask the part of those questions that is related to the reason they are being seen for that visit. The comprehensive past medical, family, social history and the comprehensive ROS can be updated annually or as needed, and then referenced. Good question!

[@harelljuanico4293]

Okay thanks for clarification! More power to you!

[@martinamulbah8013]

Thanks for sharing

[@delia5158]

Great video. Weird question- What software do you use for these videos?

[@JessicaNishikawa]

Hi Dede, Sorry this is late reply. This particular video is made with an endless whiteboard program called VideoScribe. It's great and very user friendly! Thanks for watching! :)

[@Ann-pn9or]

you also misspelled emesis

[@jomo2952]

that is helpful thank you .

[@JessicaNishikawa]

Hi Jo, you are welcome. Thanks for watching and glad you found it helpful!

[@melvayaredaguilar]

I thought this was a video about cleanliness soap

[@eightysixoneeightysix3184]

don't mind me.. im just here cos prof told me to watch.

[@malloryminer2796]

the link did not work because I do not have a UH login

[@splitaxis]

It's not subjective that he is a 62 year old male taking a bunch of meds and has specific allergies. Those are facts.

[@JessicaNishikawa]

This is SOAP notes for beginners so there are simplifications. Follow these steps though and no one will ever question your SOAP note structure.. You can certainly put information in many other sections as well as you become more versed in medical documentation. But to address your specific statement/questions, those things are subjective if the patient is telling that information to you. Ie: new patients, new patients to your group, history taking, etc. If you are seeing the patient have an allergic reaction, you would put your examination findings in the objective information. It's easiest to think of everything as subjective except for what you are seeing/examining (objective). Thanks for watching! J

[@splitaxis]

@@JessicaNishikawa Subjective is how the patient describes the symptoms of a disease / injury and their current physical /mental state according to their perception. Subjectivity does not extend into their name, age, sex, meds, PMH, PSH, allergies as those are facts. For example, subjectively they may say they are in pain but objectively there is no sign of trauma or any evidence of pain. You cannot say that subjectively they are a 62-year-old male but objectively this is a 25-year old female because you would just state a fact of their identity. You would explicitly state that "patient identifies as a 62-year-old male who is, in fact, a 25-year-old female" What you did was to mix in a 1 - 3 sentence patient introduction with subjective information. This is what makes the SOAP note confusing to others when people mix a bunch of stuff together and call it "subjective".

[@JessicaNishikawa]

@@splitaxis Thank you for weighing in with your opinions. Within the confines of a SOAP note, in which section do you suggest students put that other information.

[@splitaxis]

@@JessicaNishikawa John is a 62-year-old male with a PMH of diabetes who presents today with foot pain. SUBJECTIVELY he describes the pain as ba bla bla bla bla. OBJECTIVELY his vital are bla bla bbla and his physical exam is notable for bla bla. The style is really 1 -3 liner intro followed by SOAP. This is why so many notes include name age and sex in subjective parts in EPIC even though they don't belong there at all. It really should be ISOAP but that doesn't sound as good.

[@JessicaNishikawa]

@@splitaxis Sure! That works. You'll find out in practice it actually doesn't matter where the information is as long as the billers can find it... but organization is helpful to easily identified information for future reference.

[@viohleta]

Very helpful

[@KITAANDROO]

The words "Chief" is spelled wrong

[@marietteslabbert4642]

and LIKLY

[@AlexiHolford]

and she says he has 4/5 symptoms, but wrote 4/4

[@AlexiHolford]

Allison, there's a typo in your comment as well. You wrote "words" instead of "word."

[@maimai2344]

I thought this was the soap you use

[@melvayaredaguilar]

what is soap anyways?

[@babbulvideos]

what program did you use to make this video?

[@JessicaNishikawa]

Videoscribe. It's awesome!

[@its_taliaaa_9142]

So you wouldn't order a throat culture?

[@fani4704]

Why would family history not be included?

[@JessicaNishikawa]

It would :) Did I not mention it? I tend to leave it out of day to day practice because most of the people i work with are older adults and I find it a bit ironic to ask a 90 year old if their parents had any cancers or major medical history. :)

[@christinacidoni803]

does it make a difference when you spell words wrong? Chief

[@JessicaNishikawa]

knot reely ;)

[@Alex-bd4ov]

Great.

[@cherietrombley9568]

CHIEF IS SPELLED INCORRECTLY

[@AntoinetteChanel]

Hi there - I work in curriculum design and would like to use this video as part of the background information for an assignment I am putting together. I didn't see any contact info for you, but may I have your permission to use this video? I can explain further via email.

[@JessicaNishikawa]

Aloha - you can email me at [e-mail] . But generally speaking - you are free to use any ot

[@JessicaNishikawa]

Sorry about that--- You are free to use any of the videos.

[@samalimax1433]

Very well

[@nafisemahmoodpoor8494]

Great

[@alainaharmon2575]

From Cyber Credible

[@homeguys6133]

You increased the lisinopril without a plan to recheck his U+E and renal function :/

[@JessicaNishikawa]

Hi HOME Guys, thanks for watching and taking the time to comment. If you were watching a little more carefully you would notice that the lisinopril wasn't actually increased. It was Lisinopril 20mg and at the end was still lisinopril 20mg (insert shrug emogi). Which was actually an oversight :) But one I didn't think required correction since the video is not about HTN management but about how to write a SOAP note (see clever title and video intro). If you're looking for videos about hypertension management I could recommend resources, just let me know. Aloha!