How to Write a SOAP Note Objective
- 1). Examine the appearance of the patient. Make a note of any discoloration or wounds on the skin.
- 2). Feel the patient's skin. Look for swelling or rigidity. Check the location of the surgical site. Make a note of any deformities or complications.
- 3). Check the patient's temperature, using either an oral, rectal or axillary thermometer. Hold the thermometer in place for four seconds or until it beeps and check for a reading. Record it in your notes as "Temp" or "T" with the reading.
- 4). Assist the patient while checking weight and height. Record the weight as "WT" and height as "HT." For example, "WT = 210lbs. HT = 60."
- 5). Check the patient's pulse and blood pressure. Record the blood pressure as "BP" and the pulse "P."
- 6). Instruct the patient to stand in front of you and offer any assistance if necessary. Record, under your objective, if the patient needs assistance with walking or standing. Check for the patient's gait, endurance and posture.
- 7). Administer or arrange for the patient to take any diagnostic tests necessary. Record the results of these tests under objective.
- 8). Record any drug that's relative to the patient's condition, including dosage and frequency. Also make a note of any drug allergies.
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