Part of Unit: Documentation
Lesson Plan Overview / Details
In this lesson, students will be introduced to the concept of SOAP (Subjective, Objective, Assessment, Plan) notes and their use in the healthcare environment. They will learn the meaning of each section, and will have the opportunity to observe the instructor taking notes, participate in a full-class note taking demonstration, and practice taking their own notes (both in the class and at home).
- One Class Period --
- 52 Minutes
California Career and Technical Education Standards
- HSMT.B.B2.1 Understand the process for analyzing available information to assess the health ...
- HSMT.B.B2.2 Know the process for evaluating and appraising the appropriateness of information.
- HSMT.B.B2.4 Use appropriate documentation to report information about patients and clients.
- HSMT.C.C3.4 Formulate and report information clearly and concisely.
- HSMT.FS.11.0 Demonstration and Application
- HSMT.FS.2.0 Communications
- HSMT.FS.5.1 Apply appropriate problem-solving strategies and critical thinking skills to wor...
- HSMT.FS.5.2 Understand the universal, systematic problem solving model that incorporates inp...
- HSMT.FS.5.3 Use critical thinking skills to make informed decisions and solve problems.
Objectives and Goals
- Students will learn and apply the process for analyzing available information to assess the health status of patients and clients.
- Students will practice evaluating and appraising the appropriateness of patient information.
- Students will understand the universal, systematic problem solving model that incorporates input, process,outcome, and feedback components.
- Students will demonstrate the ability to formulate and report information clearly and concisely.
- Students will apply appropriate problem-solving strategies and critical thinking skills to their SOAP notes.
- Students will use critical thinking skills to make informed decisions and solve problems.
- Use appropriate documentation to report information about patients and clients.
- Students will demonstrate clear and effective communication in dealing with their patient.
Activities in this Lesson
- What happened?? - Hooks / Set
As the students enter the room, a “freeze-frame” of an injury video will be visible on the overhead screen. On the board, it will be written: “Take out a piece of paper. Look at the image on the screen and answer the following questions:
1. If you were present at this injury scene, what questions might you ask the person about how they are feeling and what happened?
2. What visible clues of the injury might be present? What movements and/or positions might be painful for this person?
3. What is the most likely diagnosis of his/her injury?
4. What are 2-3 types of treatment you could utilize to help this person?”.
The instructor should encourage the students to use existing knowledge to come up with answers to the questions. They are given 5 minutes or less to brainstorm and write their answers. Once the students have finished writing, play the entire video. Once the video has concluded, talk about what likely happened and what questions would be good to ask in this situation.
- PowerPoint Presentation - Lecture
The instructor will then proceed to the lecture (PowerPoint presentation) portion of the lesson. Students will take out their class notes to follow along with the presentation. The presentation will cover the acronym “SOAP” (Subjective, Objective, Assessment, Plan) as well as “CC” (Chief Complaint) and will give practical examples of each section to help students begin to understand the process of taking the notes and why they are used by healthcare providers.
- SOAP Notes.ppt [ Download ]
- Instructor Demonstration - Demo / Modeling
( IMPORTANT: Remind students that whatever is discussed in class is to stay in class – i.e. Patient Confidentiality. If they want to discuss anything outside of the classroom, they should say something like, “I know someone who…” or “I heard about a guy who…” rather than using the student’s name.) The instructor will ask for one student volunteer (preferably someone who has had a recent injury).The student will be interviewed by the instructor, utilizing the SOAP note format. Students will be permitted to ask questions as needed throughout the demonstration.
- Whole Class Guided Practice - Lab / Shop
The instructor will ask for an additional student volunteer (preferably someone who has had a recent injury). This student will be interviewed by the class, utilizing the SOAP note format. Students may volunteer to ask questions, or will be called on by me. The instructor will monitor the class to make sure there is even and adequate participation by the students, and also interject additional questions if the students miss anything he/she feels is important to ask.
- Independent Partner Practice - Lab / Shop
Once we have completed the two demonstrations, the students will be asked to interview each other in the same manner, utilizing the SOAP note format. The instructor will walk around the room and listen to the students to check for understanding and correct application of the note-taking format. Students will be expected to turn in their partner interviews for participation credit for the day.
- Homework - Projects
At home, students will be asked to do two assignments:
- Come up with a list of general, clear, concise questions that will cover the “S” (subjective) section of the SOAP notes. The questions should adequately cover all aspects of an injury, including how the pain feels, how it changes with movements or time of day, etc.
- Do an additional practice of SOAP notes on a friend or family member. If they do not have a current injury, ask them to remember back to a previous injury they have had.
Both assignments will be due at the beginning of class the next day.
- Assessment Types:
- Writing Samples, Interviews,
During this lesson, the instructor will assess student learning through:
1. Participation in the guided practice interview activity
2. Correct recording of SOAP notes from their independent partner activity in class.
3. Correct recording of SOAP notes from their homework interview.
4. Comprehensive and clear list of subjective questions from their homework assignment.