SOAPE Principle

The SOAPE principle is recommended for the systematic process of documentation. The letters stand for:
S - Subjective
O - Objective
A - Assessment
P - Plan
E – Education

This principle covers all the necessary steps to create an effective, secure and individual diagnosis .
Following the sequence of the SOAPE principle allows you to creat a consistently systematicly good documentation that can be used to build instructive case reports for training purposes.

S – Subjective (what does the subject report)

• Signs and symptoms of the patient
• Relevant medical history
• Relevant changes before symptoms appear

Examples

• Taking medication
• Change in drug dose
• Ssubjective deterioration of visual acuity
• Foreign body sensation caused by contact lenses wearing
• The appearance of flying mosquitos
• quick reading fatigue
• Dry eye by working on a computer screen
• Burning eyes after putting on cleaned contact lenses

O – Objective (what does the examiner measure)

• Performed investigations and examination results based on the subjective information
• patient-specific data
• Assessment of the results
• Discovery of new symptoms / findings
• Answer to possible questions

Example

• Slit lamp examination - curvature of the anterior surface of the cornea
• Examination of the anterior segment of the eye with fluorescein
• Refraction - change of the prescription (eg minus direction)
• Indirect ophthalmoscopy - blurred contours of the optic nerve
• increased intraocular pressure of the eye
• Foreign body under the contact lens - scratches on the corneal surface during inspection with fluorescein

A – Assessment (wich findings can be detected)

• Diagnosis based on subjective and objective results
• requires a high level knowledge of the specialist
• If necessary, referral to a specialist in other fields (e.g. ophthalmologist, cardiologist, family doctor, ...)

Examples

• Foreign bodie under the contact lens
• Damage of the contact lenses
• Keratoconus
• Presbyopia
• Solution induced corneal staining
• Allergy or intolerance to preservatives in lens care products
• Chamber angle very small / inflammatory cells in the anterior chamber

P – Plan (recommendation / intervention / treatment)

• Creation of treatment plans
• Eventual additional test for the evaluation of the treatment access
• Creation of the follow up visit plan
• If necessary, referral to a specialist in other fields (e.g. ophthalmologist, cardiologist, family doctor, ...)

Examples

• Change care products (from preserved to unpreserved)
• To prescribe a near addition
• Replacement of the contact lens / replacement of the contact lens case
• Visual training
• Removal of a foreign body
• Fitting on Ortho-K Lenses

E – Education (further information and clarification)

• Additional information for the customer/patient
• If possible, involve the subject
• Summary of necessary measures
• Explanation of the consequences and alternatives that the patient has
• Monitoring of treatment success

Examples

• Involve the patient in contact lens handling training
• Each step of placing, removing and cleaning the contact lenses should be performed by the client
• Offer additional information
• Offer follow up visit