Some Expert Guidance in Writing SOAP Notes

What Does SOAP Stand For?

SUBJECTIVE

 

The initial portion of the SOAP note format consists of subjective observations. These are symptoms the patient verbally expresses or as stated by a significant other. These subjective observations include the patient’s descriptions of pain or discomfort, the presence of nausea or dizziness, when the problem first started, and a multitude of other descriptions of dysfunction, discomfort, or illness the patient describes. OBJECTIVE

 

The next part of the format is the objective observation. These objective observations include symptoms that can actually be measured, seen, heard, touched, felt, or smelled. Included in objective observations are vital signs such as temperature, pulse, respiration, skin color, swelling and the results of diagnostic tests. ASSESSMENT

 

Assessment follows the objective observations. Assessment is the diagnosis of the patient’s condition. In some cases the diagnosis may be clear, such as a contusion. However, an assessment may not be clear and could include several diagnosis possibilities. NUR6531 Assignment Discussion Project

PLAN

 

The last part of the SOAP note is the health care provider’s plan. The plan may include laboratory and/or radiological tests ordered for the patient, medications ordered, treatments performed, patient referrals (sending patient to a specialist), patient disposition (e.g., home care, bed rest, short-term, long-term disability, days excused from work, admission to hospital), patient directions (e.g. elevate foot, RTO 1 week), and always include follow-up directions for the patient.

What is a SOAP Note?

The SOAP note format is used to standardize medical evaluations that are made in clinical records.

 

The SOAP note is written to facilitate improved communication among all involved in caring for the patient and to display the assessment, problems and plans in an organized format. NUR6531 Assignment Discussion Project

 

Many Electronic Health Records (EHR) systems are capable of producing SOAP Notes. The actual notes and other information are commonly referred to as Electronic Medical Records (EMR).

What are the components of a SOAP note?

 

The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. The length and focus of each component of a SOAP note varies.

Subjective component

This describes the patient’s current condition in narrative form. The history or state of experienced symptoms is recorded in the patient’s own words.

It will include all pertinent and negative symptoms under review of body systems in addition pertinent medical history, surgical history, family history, social history along with current medications and allergies are also recorded. NUR6531 Assignment Discussion Project

The primary care provider seeing the patient will take a History of Present Illness or HPI. To structure this portion of the note, you can use another mnemonic: OLD CARTS

· Onset

· Location

· Duration

· Character (sharp, dull, etc.)

· Alleviating/Aggravating factors

· Radiation

· Temporal pattern (every morning, all day, etc)

· Symptoms associated

Objective component

The objective component includes:

· Vital signs (including pain scale, pulse oximetry readings)

· Findings from physical examinations, such as posture, bruising, and abnormalities

· Results from laboratory tests

· Measurements, such as age and weight of the patient.

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Assessment

This section is where you write your diagnosis, or, if more than one, your diagnoses.

Some assessments also require a quick summary note of the patient with main symptoms/diagnosis. Some include a differential diagnosis (but most do not), which is a list of other possible diagnoses usually in order of most likely to least likely. NUR6531 Assignment Discussion Project

Source: Physician SOAP Notes (2015). Retrieved from: http://www.physiciansoapnotes.com/

 Guidelines for SOAP (Post Encounter Notes)Another good source for explaining how to write SOAP Notes

Introduction: “If it ain’t written down, it didn’t happen”

Good notes are essential in primary care to document changes over time that can be crucial to diagnosis and management. Thinking about the note ahead of time can improve the patient encounter.

SOAP notes are legal documents that are taken as the formal, complete record of the encounter.

Strong Hints:

1. Practice talking to patients in order to collect all pertinent data for each section at the same time.  This will aid in a smooth transition between sections.

2. Practice, practice, practice until you have comfortable phrases and sets of questions that work well for you.

3. As you finish the patient encounter “think SOAP note”. Mentally scan the expected SOAP note sections and check you have all the necessary data.

4. Organize your thoughts before starting the note so your writing time is used efficiently. Using the same phrases each time can help.

5. Be very careful about abbreviations.

6. Always be truthful – never record anything in the SOAP note that you did not do or ask.

Specific Components of the SOAP Note

History (Subjective):

Ask your patient pertinent positives and negatives from HPI, PMH, ROS, FH, SH. It is strongly suggested that you write these headings in the left margin of your note before starting as once you start to write the note, it is easy to miss a specific subheading.

HPI: Start with the age, sex, race using the formula of age, sex, race and chief complaint. e.g.

“Patient is a 40 year old white female complaining of (or presenting because of)”. If using a patient quote, mark it appropriately.

HINTS:

· Completely, succinctly describe the presenting complaint.

· Memorize a template for common problems, if possible.

· Use the mnemonics or whatever helps you to remember a “script” for common symptoms/conditions, especially pain.

· Address the pertinent positives and negatives for the specific system in the HPI for completeness (e.g. include shortness of breath, ankle swelling, etc. in a presenting complaint of chest pain)

· It is a good practice is to end with what the patient thinks or fears as the cause of symptoms.

PMH:

1. Serious illness, hospitalization, surgery

2.  Medications (includes prescriptions, OTC and herbs/supplements) give dose and duration of use if known

3. Allergies (frequently forgotten!!!) NUR6531 Assignment Discussion Project

4. Status on preventive issues – Immunizations, Pap, mammogram, colon screening, etc.

5. Always document reproductive basics in women e.g. G2P2LC2. Menarche aged 12, regular cycles 3-4/28 no clotting/cramping. Contraception by tubal ligation. In postmenopausal woman, give age and any HRT use

SH:

1. Tobacco, alcohol, substances (duration and amount of use) Check for ex-users. Be sure to ask in patients you don’t suspect of “vices”. If you get a positive response, you need to do a more detailed history for alcohol or tobacco or substance.

2. Occupation and/or educational history (just key issues, mainly exposures and stressors).

3. Living situation (who lives at home, any stressors, sexually active).

4. Health habits especially diet and exercise but can include hobbies.

 

FH:

1. Cause of death/significant health problems for parents

2. Significant health problems in siblings

3. Close relatives with heart disease, stroke, diabetes, hypertension, cancer or “anything that runs in the family”

4. Other questions depend on case – e.g. ask more in a breast cancer case about relatives with cancer or ask about sudden deaths in a palpitations case.

ROS:  Brief scan of key symptoms in each system. Don’t forget mood!

Physical Exam: (Objective)

You are required to do focused physical examinations. You must select which systems to examine based on the data required to diagnose and/or manage the case. If you do too much PE, you are taking time away from history and negotiation with the patient. The key exams are:

1. Vital Signs

2. General Impression of Patient:

HINT: Lots of individual variation in how this is recorded. Keep this brief but comment on:

1. Appearance (body habits). Mainly weight (obese, overweight, thin, appropriate for height). In some cases, signs of recent weight loss are relevant.

2. Distress/pain. General appearance and apparent severity of pain or distress and relevant issues such as holding a specific body part, restless, or unwilling to move for pain e.g. “appears to be in severe pain, lying still with knees drawn up.”

3. General affect/demeanor. Usually focuses on anxiety or depression. Can include general cooperation or ability to answer questions as “alert, pleasant, upbeat, very talkative”. elderly lady; also used to document anger, hostility, use of inappropriate language.

4. Other pertinent issues. Specific issues relevant to each case e.g. skin tones – pale, jaundiced, plethoric (rashes and obvious external lesions should have a specific entry in PE): sweating or shivering: smells (e.g. ketotic, alcohol): clothes and grooming may be important as clinical indicators e.g. of self-neglect.

3. Pertinent System(s) Exam:

Systematically record the pertinent positive and negative findings for the systems(s) you examine using subheadings to organize your findings. In conditions like diabetes and hypertension that cause systemic damage, prioritize the target organs like fundi, heart size, peripheral nerves and circulation.

4. Any Specific Exams:

Special items may be appropriate to individual cases.  If necessary, do not hesitate to ask the patient for permission to do a “sensitive” examination (breast, prostate, rectal, pelvic) and document the information you receive.

If the patient does not consent but you still think the data from the exam is necessary, document “refused” or “declined” and put “arrange pelvic (or other sensitive) exam” in the diagnostic plan.

Differential Diagnosis (Assessment)

In assessment you synthesize the data you have collected from the H&P into plausible medical explanations AND your sense of the most probable diagnoses for this presentation in the specific type of patient seen (e.g. severe RIQ abdominal pain could be caused by appendicitis in a child, ovarian or tubal conditions in a woman of reproductive age, diverticular disease in an elder, inguinal hernia in a young man). NUR6531 Assignment Discussion Project

HINT:

1. Name specific medical diseases or conditions and use correct medical terminology and spelling – do not repeat symptoms in your assessment.

2. The conditions should be listed in order of probability – you have to commit!

3. The evidence for the conditions listed must be in the note. For example, you cannot list depression if relevant signs, symptoms, history have not been subjectively reported or objectively seen and documented.

Diagnostic Plan.

Diagnostic tests can include:

· laboratory tests

· imaging studies

· questionnaires and special tests like psychometric or pulmonary function

· specific data gathering such as obtaining BP measures at community sites, keeping pain or symptom  or food intake diary. NUR6531 Assignment Discussion Project

Also in the diagnostic plan are:

· Specific treatments (e.g. Medications – use generic names and be as specific as possible regarding dose, length of therapy, how it should be used etc.)

· Ancillary treatments such as physical, occupational therapies

· Patient/family education

· Community support/resources

· Prospective care/preventive services

· FOLLOW UP (this is essential!)

Resources

The USMLE-CS website has information and shows the templates for notes:

http://www.usmle.org/Examinations/step2/cs/content/appendixB.html

http://www.usmle.org/examinations/step2/cs/2009CSinformationmanual.pdf

 

Sample Write-Up (THIS SAMPLE IS VERY EXTENSIVE, DON’T BE AFRAID)Patient ID: Mr. H

Chief Complaint: Abdominal pain

History of Present Illness

Mr. H is a 65 year old white male with a past medical history significant for an MI and depression who presents today complaining of sharp, epigastric abdominal pain of 3-4 months duration. The abdominal pain has been gradually worsening over the past 3-4 months. The pain has not changed or worsened acutely; Mr. H seeks care for the pain at this time because he is now covered by Medicare. The pain is located in the epigastric region and left upper quadrant of the abdomen. It does not radiate. The pain is relatively constant throughout the day and night but does vary in severity. Mr. H rates the pain as 6/10 at its worst. Mr. H describes the pain as a “sharp, burning” pain. He has not tried taking any medicines to relieve the pain. The pain is not alleviated with rest. Mr. H thinks the pain may be aggravated by throwing the football, but he has also experienced the pain independent of playing football or exerting himself. The pain is not associated with food or eating, although Mr. H does endorse occasional heartburn. Mr. H thinks the pain may at times be worse lying down, and it does wake him up at night. Mr. H denies any abdominal trauma or injury. He endorses a 5lb weight loss over the past 3-4 months, decreased appetite, and fatigue. He has experienced some drenching night sweats, requiring him to change his shirt but not his sheets. He describes a “lump in his throat” with associated dysphagia. He has experienced some nausea with the abdominal pain but has not vomited. He endorses constipation. He endorses bloody stools with some bowel movements. The blood is dark red in color and is not bright red. There is a sufficient amount of blood to turn the toilet water red. Mr. H does not know how many times per week he experiences this bleeding. He has not seen a bloody bowel movement in the past week. NUR6531 Assignment Discussion Project

Past Medical History

Other active health problems:

· Hypertension, diagnosed “years ago,” well-controlled with Metoprolol

· Depression, poorly controlled; started Prozac 6 months ago but still feels depressed

Hospitalizations: MI, 2004

Surgeries/procedures: Cardiac catheterization, post-MI, 2004

Medications

Aspirin 81mg po qd since his MI 3 years ago

Metoprolol 100mg po qd “for years”

Prozac 20mg po qd; Started 6 months ago

Protonix discontinued 12-18 months ago

Allergies: No Known Drug Allergies, no food or insect allergies

FH

Mother died at age 74 of “natural causes”; mother had HTN “for many years”

Father’s medical history not known

No known family history of colon cancer.

SH

Mr. H is a retired factory worker. He is divorced and has six children and one grandchild, whom he sees almost daily. Despite this, Mr. H says he still often feels alone, isolated, and depressed. He denies past or present tobacco and illicit drug use. He denies alcohol use. Mr. H does not have health insurance but is now covered by Medicare. NUR6531 Assignment Discussion Project

ROS

General – As indicated in the HPI, denies fevers or chills; endorses decreased appetite and a 5lb weight loss over the past 3-4 months; endorses fatigue

HEENT:

· Head – denies headache, dizziness, syncope

· Ears – denies difficulty or changes in his hearing, denies tinnitus

· Eyes – denies problems or changes in his vision; denies blurred vision; denies seeing spots

· Nose – Not assessed

· Throat – complains of a “lump in his throat;” endorses dysphagia

Cardiovascular – denies chest pain; denies palpitations

Pulmonary – denies shortness of breath, denies cough

Gastrointestinal – As indicated in the HPI, complains of sharp, epigastric abdominal pain; endorses constipation, denies diarrhea; endorses bloody stools

Genitourinary – denies dysuria; denies increased frequency or urgency of urination

Neurologic – denies numbness and tingling; denies paresthesias

Musculoskeletal – endorses abdominal pain occasionally after throwing the football; denies any muscle or joint pain. NUR6531 Assignment Discussion Project

Endocrine – not assessed

Hematopoietic – denies easy bruising

Physical Exam

Vital signs: Ht. 5’10” Wt. 160lbs, BMI 28, HR 72, RR 16, BP 126/78, Temp 99.0

General: Mr. H is a depressed-appearing white male in no acute distress.

HEENT: Not examined

Lymph nodes: Non-tender, no palpable masses

Neck: No masses

Cardiovascular: Regular rate and rhythm; normal S1, S2; no murmurs, rubs, or gallops

Lungs: Lungs clear to auscultation bilaterally; No wheezes or crackles

Abdominal:

· Abdomen soft and non-distended with no scars or striations

· No pulsatile masses, no abdominal bruits auscultated

· Spleen not palpable, liver not palpable

· Tender to palpation in epigastric region and left upper quadrant; No reflex tenderness; No guarding; Murphy’s sign negative

Rectal: Hemoccult positive

Genitourinary: Not examined

Neurologic: Not examined

Musculoskeletal: Not examined

Laboratory Data: None collected

Diagnostic Tests: Hemoccult positive stool

Assessment:

1. Abdominal Pain

2. GI Bleed

3. Depression

4. Hypertension

Problem #1: Abdominal pain, bloody stools/GI Bleed

Differential diagnosis: colorectal adenocarcinoma, gastric ulcer, duodenal ulcer, GERD, intestinal obstruction, anxiety or depression related, abdominal aortic aneurysm, pancreatitis, pancreatic cancer

Diagnostic plan: Colonoscopy to evaluate the colon for presence of polyps or tumors

Therapeutic plan:

· If colon cancer is detected on colonoscopy, refer Mr. H to a GI oncologist.

· Restart Protonix therapy

· Treat constipation with laxative as needed or daily Metamucil

Patient Education: The importance of colonoscopy screening for colon cancer was discussed with the patient.

Problem #2: Depression

Therapeutic plan: Continue Prozac 20mg po qd for now. Consider switching to a different anti-depressant. Discuss counseling and therapy options.

Problem #3: Hypertension

Therapeutic plan: Continue Metoprolol 100mg po qd

Patient education: The importance of dietary salt and fat restriction and exercise were discussed with the patient

Follow up: Schedule appointment for return in 2 weeks.

Discussion and Logic for Diagnosis

(This is the argument for the decision making and actions taken; THIS IS NOT typically found in SOAP notes)

Given Mr. H’s age, history of bloody stools, Hemoccult positive stools on exam today, and the gravity of missing a cancer diagnosis, colorectal adenocarcinoma should be considered first in the differential. “Increasing age is probably the single most important risk factor for colorectal cancer in the general population. Risk increases steadily to age 50, after which it doubles with each decade” (Ruben, 608). Colon cancer is usually initially clinically silent and most commonly presents as hemoccult positive stools. However, large tumors can cause intestinal obstruction and associated constipation and abdominal pain. “A positive test result for fecal occult blood predicts the presence of a cancer or an adenoma in 50% of cases” (Ruben, 609). “Colon cancer is the second leading cause of cancer-related death in the United States” (American Cancer Society). However, if detected early and at a low stage, surgery can be curative.

Thus, at age 65, Mr. H is at risk for colorectal cancer. Furthermore, Mr. H’s bloody stools, hemoccult positive stool, weight loss, constipation, and abdominal pain are worrisome for cancer and possible intestinal obstruction by tumor. Therefore, based on this clinical presentation and the life-saving importance of early detection, Mr. H should first be evaluated for colon cancer by colonoscopy.

Gastric and duodenal ulcers can also cause epigastric abdominal pain and bloody stools, secondary to gastric bleeding. “The symptoms of gastric and duodenal ulcers are similar…[both are] characterized by epigastric pain 1 to 3 hours after a meal, or that awakens the patient at night” (Ruben, 567). Heartburn, nausea, and weight loss can also occur with gastric and duodenal ulcers.

Although Mr. H does not associate his abdominal pain with food or meals, his pain does wake him up at night. Furthermore, Mr. H’s abdominal pain onset 2 months after discontinuing Protonix, and he has experienced heartburn, nausea, bloody stools, and weight loss, all of which can be associated with gastric and duodenal ulcers. Therefore, gastric and duodenal ulcers should be considered next in the differential (Ruben, 567-568)

Gastroesophageal reflux disease (GERD) can also cause epigastric abdominal pain. Based on the onset of Mr. H’s abdominal pain 2 months after discontinuing Protonix, and his symptoms of a lump in his throat, dysphagia, heartburn, and nausea, GERD should be considered next in the differential (Ruben, 553-555).

Restarting Protonix therapy will decrease the amount of acid produced in Mr. H’s stomach and should alleviate symptoms resulting from gastric and duodenal ulcers and GERD. Therefore, if Mr. H’s abdominal pain is relieved with Protonix therapy; it can be attributed to one of these gastric-acid based conditions.

Finally, intestinal obstruction secondary to chronic constipation should be considered as a possible contributing factor to Mr. H’s abdominal pain. While such an obstruction could explain Mr. H’s pain, it does not explain his worrisome symptoms of bloody stools or the finding of Hemoccult positive stool and should therefore be considered in addition to another, more complete, explanation.

Similarly, anxiety or depression related abdominal pain, abdominal aortic aneurysm, pancreatitis, and pancreatic cancer would not explain Mr. H’s bleeding and, like intestinal obstruction, should only be considered in addition to another, more complete, explanation. NUR6531 Assignment Discussion Project

Sources

Rubin, R. and Strayer, D. Rubin’s Pathology. 5th edition. Lippincott Williams and Wilkins, 2008.

Source: http://www.kumc.edu/school-of-medicine/office-of-medical-education/clinical-skills-lab/student-tools/guidelines-for-soap.html

PATIENT CASE BACTERIAL PNEUMONIA

Chief Complaints

Provided by patient’s home caregiver: “Mrs. I. is confused and very sick. She was up most of last night coughing.”

HPI

Mrs. B.I. is an 84-year-old white female, who is widowed and a retired bank manager. She owns her own home and has a 45-year-old female caregiver who lives in the home. Currently Mrs. I. uses a walker and takes daily strolls to the park with her caregiver. She is able to perform most activities of daily living; however, the caregiver prepares all meals. The patient presents to the clinic accompanied by her caregiver, who reports that Mrs. I. has a one-week history of upper respiratory symptoms and a two-day history of increasing weakness and malaise. Approximately three days ago, the patient developed a cough that has gradually become worse and she now has difficulty catching her breath. The caregiver also reports that the patient was confused last night and nearly fell while going to the bathroom. The patient has been coughing up a significant amount of phlegm that is thick and green in color. She has no fever. The caregiver has become concerned by the patient’s reduction in daily activities and an inability to get rid of her “cold.” Patient Case Question 1. Based on the patient’s history of illness, is this type of infection considered community-acquired or nosocomial? Alterations In Pulmonary Function. Alterations In Pulmonary Function Assignment

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PMH

Tobacco dependence × 64 years Chronic bronchitis for approximately 13 years Urinary overflow incontinence × 10 years HTN × 6 years, BP has been averaging 140/80 mm Hg with medication Mild left hemiparesis caused by CVA 4 years ago Depression × 2 years Constipation × 6 months Influenza shot 3 months ago FH (+) for HTN and cancer (−) for CAD, asthma, DM

SH

Patient lives with caregiver in patient’s home Smokes 1/2 ppd Some friends recently ill with “colds” Occasional alcohol use, none recently

ROS

Difficult to conduct due to patient’s mental state (lethargy present) Caregiver states that patient has had difficulty sleeping due to persistent cough Caregiver has not observed any episodes of emesis but reports a decrease in appetite Caregiver denies dysphagia, rashes, and hemoptysis

Patient Case Question 2. Provide a clinical definition for lethargy

Meds

Atenolol 100 mg po QD HCTZ 25 mg po QD

Aspirin 325 mg po QD Nortriptyline 75 mg po QD

Combivent MDI 2 puffs QID (caregiver reports reports patient rarely uses)

Albuterol MDI 2 puffs QID PRN Docusate calcium 100 mg po HS

All PCN (rash) 

PE and Lab Tests

Gen

The patient’s age appears to be consistent with that reported by the caregiver. She is well groomed and neat, uses a walker for ambulation, and walks with a noticeable limp. She is a lethargic, frail, thin woman who is oriented to self only. The patient is also coughing and using accessory muscles to breathe. She is tachypneic and appears to be uncomfortable and in moderate respiratory distress. Alterations In Pulmonary Function

Vital Signs See Patient Case Table 13.1

Skin

Warm and clammy (−) for rashes HEENT NC/AT EOMI PERRLA Fundi without lesions Eyes are watery Nares slightly flared; purulent discharge visible Ears with slight serous fluid behind TMs Pharynx erythematous with purulent post-nasal drainage Mucous membranes are inflamed and moist

Neck

Supple Mild bilateral cervical adenopathy (−) for thyromegaly, JVD, and carotid bruits

Lungs/Thorax

Breathing labored with tachypnea RUL and LUL reveal regions of crackles and diminished breath sounds RLL and LLL reveal absence of breath sounds and dullness to percussion (−) egophony

Cardiac

Regular rate and rhythm Normal S1 and S2 (−) for S3 and S4

Abd

Soft and NT Normoactive BS (−) organomegaly, masses, and bruits

Genit/Rect Examination deferred

MS/Ext (−) CCE Extremities warm Strength 4/5 right side, 1/5 left side Pulses are 1 + bilaterally

Neuro Oriented to self only CNs II–XII intact DTRs 2 + Babinski normal

Laboratory Blood Test Results See Patient Case Table 13.2

Patient Case Question 5. Should this patient be admitted to the hospital for treatment? Patient Case Question 6. What is this patient’s 30-day mortality probability?

Patient Case Question 7. Identify two clinical signs that support a diagnosis of “double pneumonia.”

Patient Case Question 8. Identify five risk factors that have predisposed this patient to bacterial pneumonia.

Patient Case Question 9. Identify a minimum of twenty clinical manifestations that are consistent with a diagnosis of bacterial pneumonia.

Patient Case Question 10. Propose a likely microbe that is causing bacterial pneumonia in this patient and provide a strong rationale for your answer.

Patient Case Question 11. Identify two antimicrobial agents that might be helpful in treating this patient.

Patient Case Question 12. The patient has no medical history of diabetes mellitus, yet her fasting serum glucose concentration is elevated. Propose a reasonable explanation.

Patient Case Question 13. Why is this patient afebrile? Alterations In Pulmonary Function Assignment

Patient Case Question 14. Is there a significant probability that bacterial pneumonia may have developed from a urinary tract infection in this patient?

Patient Case Question 15. Explain the pathophysiologic basis that underlies the patient’s high blood pH. Patient Case Question 16. The chest x-ray shown in Patient Case Figure 13.1 reveals pneumonia secondary to infection with Mucor species in a patient with poorly controlled diabetes mellitus. Where is pneumonia most prominent: right upper lobe, right lower lobe, left upper lobe, or left lower lobe?

 

PATIENT CASE FIGURE 13.1

Chest x-ray from a patient with pneumonia due to infection with Mucor. See Patient Case Question 16. (Reprinted with permission from Crapo JD, Glassroth J, Karlinsky JB, King TE Jr. Baum’s Textbook of Pulmonary Diseases, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2004.)

 

Bruyere, Harold J.. 100 Case Studies in Pathophysiology (Kindle Locations 1434-1453). Wolters Kluwer Health. Kindle Edition. Alterations In Pulmonary Function Assignment