A SOAP note is a document structure that entails four strategic phases as a method employed by health care practitioners to create a patient’s chart. The basic concept of SOAP notes is to allow the health caregivers to record their professional documents in a simple and easily manageable format so that they can be stored and retrieved more conveniently by the health care practitioners when the need to do so arises. Each of the four parts of the SOAP notes method are designed to provide current and accurate information on the pregnant mother’s health progress, which includes the health status of the unborn baby. The SOAP notes system keeps records of their patient’s medical issues if any, complaints and progress for easy accessibility and formulation of a treatment plan for the health practitioners involved. The four phases include;
- Subjective
- Objective
- Assessment
- Plan
By using the four phases mentioned above a SOAP note can be quite utile in maintaining a healthy pregnancy. This article elaborates on how a chiropractor would use these SOAP notes phases to help keep your pregnancy safe.
Subjective
This is the initial phase which entails a narration of your history as well as the primary reason for your visit to the physician or chiropractor. The history includes the onset of whatever pain or discomfort you may feel during your pregnancy and your registration as a patient. The chronology of your pain including the information pertaining to the intervals and severity of your pain are all contained within the subjective phase. With the information provided within these records, the chiropractor/physician are able to analyze what might be causing the pain. Such data for chiropractic SOAP notes for instance can be useful in helping the chiropractor formulate relevant chiropractic exercises that will relieve your pain with consideration to keeping our pregnancy safe. Any additional information such as other symptoms or previous treatments and their relatability to the state of your pregnancy are recorded in the subjective phase and could be relevant to the diagnosis and treatment strategy as you will see later in this article.
Objective
As the second stage of the document the objective phase entails the factual, repeatable and traceable details about your health status as well as your baby’s. In this document information pertaining to your physical examination discoveries such as your vital signs, posture, bruising and any other available abnormalities as per laboratory results are recorded. This document also includes other factual information such as age, height and weight. All these information, though some may not seem like it has relevance but would help in the formulation of a relevant treatment plan.
Assessment
The Assessment document entails the chiropractor/physician’s medical diagnosis for the medical diagnosis alongside the date that the note was recorded. The reason for documenting this chiropractic SOAP note is also included within this part of the document. The information contained in this section becomes useful in the provision of easily accessible information to be used during your treatment process. The four SOAP notes phases entail industry guidelines and solutions that would help to properly alleviate your pregnancy-related pains (if any).
Plan
This final part of the SOAP notes involves a description of the strategy that the chiropractor/physician will use to approach the patient’s treatment. The treatment approach described in this stage is based on the information recorded in the Assessment stage and it involves health protocols such as contacting labs, prescribing medication, referrals and other relevant procedures carried out by the chiropractor/physician. It also includes data on how the selected treatment plan affects you and your pregnancy.
Conclusively, from a generalized view the SOAP notes system may seem time-consuming and cumbersome. However, its effectiveness outweighs whatever time it may take to create these notes and pregnancies have been made safer and less complicated due to chiropractic SOAP notes. By recording the source of your pain, its understanding and treatment plan a chiropractor can effectively align your spine to improve your health and your baby’s.
