Lecture 10 - SOAP Notes

purpose of SOAP note

provide a structured and clear way to record information about a patient's condition, allowing for better communication, improved patient care, and more accurate record-keeping

chart documentation

notes documented by healthcare professional that summarize patient care visits that are allowed to be written with permission of health care institution

acronym SOAP

S– Subjective

O– Objective

A – Assessment

P – Plan

standard elements of SOAP note

 Chief complaint (CC)

 History of Present Illness (HPI)

 Past Medical History (PMH)

 Social History (SH)

 Family History (FH)

 Allergies (ALL)

 Medication History

 Review of Systems (ROS)

 Physical Exam (PE)

 Laboratory Tests & Diagnostic

 Assessment

 Plan

aspects of “S”

 Chief complaint (CC)

 History of Present Illness (HPI)

 Past Medical History (PMH)

 Social History (SH)

 Family History (FH)

 Allergies (ALL)

 Medication History

 Review of Systems (ROS)

subjective information

Information given by the patient, family members, significant others, & caregivers that cannot be measured and sometimes not accurate

Subjective - CC

chief complaint; complaints/symptoms in patient’s own words, brief patient of why they are seeking medical care, often in terms of a question

Subjective - HPI

paragraph containing information from the patient pertaining to the problem(s), such as duration, timing, what relieves/worsens symptoms; often includes demographic information (age, gender) and abbreviated name

Subjective - PMH

problems identified prior to current visit, such as chronic problems and surgical procedures; include duration/date if known

Subjective - SH

basically name as social history for patient interviewing

Subjective - FH

basically name as family history for patient interviewing

Subjective - Allergies

basically name as allergies for patient interviewing

Subjective - Medications

basically name as medications for patient interviewing; make sure to note significant past medications

Subjective – Review of Systems

General description of patient’s symptoms per body system; may not include all areas of body, depends on condition presenting with

Subjective – Review of Systems areas

• HEENT (head, eyes, ears, nose, throat)

• Cardiovascular

• Respiratory

• Gastrointestinal

• Genitourinary

• Musculoskeletal

• others, if need be

Objective (“O”)

measurable and observable data often gathered from physical assessment/physician notes/lab tests; include vital signs and physical exam (PE) general descriptive statement by organ system

vital signs in objective

BP, HR, RR, Temp, Ht, Wt

ROS vs. PE

ROS is patient reported and not numerical, PE is actual values recorded at office by medical professionals

assessment (“A”)

list of problems patient has (with actual identification of disease state) in a numbered list based on pertinence of issue (usually CC #1); Should be supported by information documented in “S” and “O”

problem classification in assessment

make sure to note:

• severity of problem

• treatment status

• list recognized disease classification symptoms (if available)

• probable cause of issue if easily determinable

use words like: controlled/uncontrolled, stable/unstable, improved/unimproved/worsening

assessment in terms of medication-related topics

indication, effectiveness, safety, adherence to medications should be noted

plan (“P”)

Detailed plan of action for the problems identified outlining actions needed to resolve problems; should include goals of therapy, drug therapy, nonpharmacologic therapy, monitoring parameters, education, and follow-up plan

joint commission do not use list

• U for unit

• IU for international unit

• qd/QD for daily

• qod/QOD for every other day

• trailing zeroes

• lack of leading zeroes

• MS

• MSO4 and MgSO4