Before your virtual consult ends with a HealthTap doctor, the doctor will provide you with a consult Summary Note or SOAP note. The SOAP note is an acronym for subjective, objective, assessment, and plan and service as a method of documentation of your consult.
- This is typically a very brief statement of the purpose of the virtual consult. The doctor will describe your current condition in narrative form and the history or state of experienced symptoms are recorded here as you stated them during the consult. It will include all pertinent and negative symptoms under a review of body systems. Pertinent medical history, surgical history, family history, and social history, along with current medications, smoking status, drug/alcohol/caffeine use, level of physical activity and allergies, are also recorded. Subsequent visits for the same problem briefly summarize the history of present illness, including pertinent testing and results, referrals, treatments, outcomes, and follow-ups.
- This is where the doctor will extract observations or measurements from your symptoms such as:
- Vital signs and measurements
- Basic systems of cardiac and respiratory functions
- Any abnormalities
- Results from any lab or diagnostics tests already completed
- This is where the doctor will provide a medical diagnosis for the purpose of the medical visit on the given date. This will also outline any main symptoms and other possible diagnoses usually in the order of most likely to least likely. If you have already consulted with the doctor it may include progress since the last visit and overall progress towards your goal from the doctor's perspective.
The plan is what the doctor action to treat your concerns. This could include ordering further labs, referring to another doctor who specializes in specific care, or outline procedures that need to be performed. Medications are also administered here. The plan could also include goals of therapy and patient-specific drug and disease state monitoring parameters.
If you have multiple health problems that are addressed in the SOAP note, a plan is developed for each problem and is numbered accordingly based on severity and urgency for therapy. A note of what was discussed or advised with you as well as timings for further review or follow-up are generally included.