Should You Always Fill Out a SOAP Note?

In combination with our patient assessment system and field handbook, we use SOAP notes to help teach students how to assess and treat patients. They quickly see the benefit in a well-designed SOAP note, especially for complex problems; however, they often question if a SOAP note should be used for every patient? After all they take time to complete (and everyone hates paperwork, particularly if it's seen as unnecessary). So...what's necessary and what isn't?

Sometimes the answer is obvious: The problem is serious and/or complex and a SOAP note is necessary. But what about minor problems, for example: blisters, strains and sprains, cuts, etc.; and problems that may, or may not, develop into something more serious, like hymenoptera stings that may progress to anaphylaxis, a blow to the head that may turn out to be a mild concussion, or a drowning patient who was awake throughout their rescue but coughing, etc. These are not so obvious, usually because they don't require an evacuation at the moment...but could in the future. What about them?

There are a couple of ways to proceed; both are valid:

1. Complete a SOAP note and incident report. After all, it only takes a few minutes. While a SOAP note may ultimately turn out to be unnecessary, you've covered your bases. And, it's programmatically important to keep track of even minor incidents in case they might point to field or administrative errors that need addressing.
   
2. Write down basic information in your notebook (patient's name, presenting S/Sx, problem, and treat/monitor the patient. If developing S/Sx warrant closer attention, transfer the information to a SOAP note and continue from there. Remember to complete an incident form.

Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available.

Download a free pdf copy of our 2018 SOAP note for you personal or institutional use; print on 8.5 x 14 legal paper and fold into thirds. Many not be used to teach © 2018 WMTC.