Final answer:
SOAP notes include Subjective information from the patient, Objective data from observations and tests, an Assessment based on these findings, and a Plan for the patient's care and treatment.
Step-by-step explanation:
The basic information included in SOAP notes encompasses clear and systematic documentation for healthcare professionals when they are treating patients. The acronym SOAP stands for Subjective, Objective, Assessment, and Plan.
Subjective information includes the patient's own description of their symptoms or concerns, potentially including when and where the health issue occurred, and the patient's feelings or experiences related to the condition. It can also reflect prior conversations with the healthcare team or the patient's own reflections on their health status.
The Objective component includes factual, measurable data such as vital signs, the results of physical examinations, lab tests, and any other diagnostic information. This could incorporate confirmation that items such as needles and sponges are accounted for after a surgical procedure or that specimens are correctly labeled with the patient's name.
Assessment is where the healthcare provider puts together the subjective and objective information to make a professional judgment about the patient's condition, including identification of any problems or diagnoses.
Plan is the final section which outlines the proposed course of action, further testing, treatments, or interventions, and includes consideration for patient recovery and care needs as discussed among the surgical, nursing, and anesthesia teams.