In a nutshell, SOAP notes allow health care practices to record documentation in a simple, easily-manageable way that will be stored so other healthcare providers may access that documentation at any time they please. The SOAP method is made up of four phases, each one designed to make sure the information about you and your baby is current and accurate. This system documents thousands of patient records regarding medical problems and complaints, and makes it easily accessible for those providers.
These phases are called:
Let’s look more deeply at what these phases are, and how they help ensure the bun in your oven, as well as yourself, is safe.
This part describes your history and details the primary reason you’re visiting the physician/chiropractor. This history includes the initial intake forms you signed before you were taken on as a client. This is where all your pain-related information is stored and preserved, including any changes. (Does the pain “move”? Does it occur at intervals or is it non-stop?) This will give them a clearer idea of what is causing that pain, and what manipulation procedures they will have to perform to relief you of that pain, while keeping your baby safe and unharmed.
This area includes all documentation regarding the results and facts of your vital signs, physical examination discoveries (what your posture is, do you have any inside bruising as well as any other abnormalities). Other typical information will be recorded here, as well. This includes your height, weight, age, etc.
This part lets physicians document your medical diagnosis, as well as the date and reason behind the chiropractic soap note being written. This chiropractic documentation of consistently recording relevant, timely data results in easily-accessed information during your treatment. These Chiropractic Soap notes are industry guidelines that must be adhered to, in order to make sure you and your baby-related pains (if applicable, as each expecting mother’s case is different) receive the proper solutions you require. The “Assessment” stage of SOAP is the documentation of what those solutions will be.
This part describes what, specifically needs to be done to put the desired solution—of the Assessment phase—into action. Here is where the physician/chiropractor/health professional will contact labs, make referrals, and document prescribed medications, among many other areas related to your care and health. This could include home recommendations, if subsequent visits are needed, and how you (and your baby) are particularly responding to the assessed treatment.
What you probably don’t know is that the SOAP note documentation method (or “problem-oriented medical record”) was created by Dr. Lawrence Weed in 1970. Until then, healthcare providers had shoddy, unorganised (and time-wasting) documentation methods. Although this new SOAP note process seems clinical and time-consuming, it isn’t.
All of this is for what matters most: the health of your baby. By keeping your skeletal structure aligned, the weight of your expanding belly won’t warp your spine. Proper chiropractic practices that use industry-standard SOAP notes help you. This is because the system documents any reactions (like vomiting and nausea) to certain solutions and treatments. This helps to keep the immune systems of both you and your baby optimally operating as they should, and you two as happy as and healthy as you should be.