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How to chart SOAP notes
Posted: January 7th, 2009 @ 1:37pm
SOAP notes enables skin and body therapists to keep an accurate record of the client’s response to treatment by using a universal system that incorporates both what the client tells the therapist and what the therapist may notice / palpate while working with the client. SOAP charting allows therapists to keep important information organized and clearly documented for each client and it is the tool we use to communicate with other health care practitioners. SOAP notes are divided into four sections: Subjective, Objective, Assessment and Planning.
Everything the client tells you from the inteview, conversations, intake forms, and questionnaires.
- The CLIENTS Goals
- Medical History (health conditions, medications - include date of incident and treatment received. If there aren't any, say there are none
- All PRESENT conditions and their locations
- Describe the INITIAL ONSET and CAUSE of conditions
- Things that AGGRAVATE / ALLEVIATE conditions
- CHANGES in the client's regime as a reult of the symptoms
- Copy all relevant information from their intake form
- Use any appropriate ILLUSTRATIONS on the SOAP note to chare indications, contraindications, conditions, etc.
Your analysis findings, visual observations (pore size, pigmentation, etc.) assessment results (hydration, textyure, etc) and YOUR treatment goals for the client.
- Visual observations - describe the client's pore size, hyperpigmentaiton, and fine lines. Note any areas that may be questionable or may need to be seen by a dermatologist
- Note areas that are lacking or are excessive in sebum production
- Describe texture and hydration / dehydration levels
- Describe YOUR treatment goals for this clinet. Include specific goals for THIS treatment and what products or equipment you will use to achieve them
Record specific changes that are an immediate result of THIS treatment.
- Describe the type of treatment performed
- Specific conditions of the face treated and techniques / modalities performed
- DETAILED description of specific changes in the client's conditions (hydration, fine lines, etc.) and the specific techniques used to affect these changes
- Techniquest used today that were effective / ineffective (and how you would modify or replace it for next treament)
DESCRIBE your plan for FUTURE treatments and FREQUENCY of treatments for this client
- Client's individual technique preferences / dislikes
- Client's future goals / esthetician's future goals
- Recommended frequency of treatment
- Suggested homecare for client - specific products, fequency of use, and HOW the client should use them (don't assume they know)
- Professional referrals - Nutritionist, dermatologist, etc.