Scribology SOAP notes

What does SOAP stand for?

subjective, objective, assessment, and plan

what is a soap note?

method of documentation for providers of the patented encounter in the ED that day. typically recored in patented EMR/EHR

what does subjective component of the EMR/EHR include?

any information that comes from the patient or their family. includes when it all started, symptoms, any any other important information such as medical history.

what does objective component of the EMR/EHR include?

information from the provider. includes information that can be measured, seen, heard, felt, or smelled, vitals, temp, diagnostic test, and especially the MDM.

what does the assessment component of the EMR/EHR include?

diagnosis of the patients condition. aka the result of the providers MDM.

what is the plan component of the EMR/EHR?

what the provider plans to do with the patient; admit or discharge. also includes the results, follow up, discharge paperwork, and prescriptions.

chief complaint

two or three word summary of why a patient has come to ER

Ex of chief complaint

Headache, cough, back pain, and chest pain

HPI

section of note where scribe documents story of why patient came to the ED. it is told from patient’s perspective and seeks to give detailed explanation why patient is needing medical treatment along with summarizing medical history.

elements of HPI

location/radiation

context

duration

onset

characer

related symptoms

alleviated/aggravating factors

severity

context

what was going on when the patient started experiencing these symptoms

onset

when the patient experiences signs or symptoms

location

place on the body where the patient is experiencing signs and symptoms

radiation

whether or not pain or symptoms move anywhere

severity

describes how bad the patient’s problem is

related signs and symptoms

any problems in addition of the chief complaint the patient complains or denies

alleviating/aggrovating factors

things patient has done to try to alleviate signs or symptoms. also, things that make symptoms better or worse

character

characteristics of chief complaint or sign or symptoms and is usually an adjective. ie. throbbing, shooting, pounding, crushing

duration

length of time the patient’s signs or symptoms exist

COLD CARS

mnemonic for HPI elements

prior medical history

previous diagnosis that the patient may have

prior surgical history

previous surgeries patient has had performed

social history

environmental facts that can affect patient’s condition. may include smoking status, alcohol usage, current marital status, current living condition. for children, can include parent’s marital status, parent’s occupation, and whether or not child is daycare.

family history

any diagnosis that the patients immediate family may have been diagnosed with in the past. primarily first degree relatives (parents, siblings, children)

ROS

briefly covers all body systems by asking yes or no questions. can be thought of as a “catch all” for everything going on with the patient at time of examination. characterized by functional organ system

Constitutional

positive fever, feeling unwell (positive malaise)

eyes

sensitivity to light (positive photophobia), negative eye pain

cardiovascular

negative chest pain, irregular heart rate (positive palpitations)

HENT

positive sore throat, no runny nose (positive rhinorrhea)

respiratory

shortness of breath (positive dyspnea), no blueness of the skin (negative cyanosis)

gastrointestinal

positive nausea and vomiting, stomach pain (positive abdominal pain)

genitourinary

painful urination (positive dysuria), no blood in the urine (negative hematuria)

mesculoskeletal

muscle pain (positive myalgia), bone pain (positive arthralgia)

nervous

positive weakness, negative facial droop

skin

itchy rash (positive pruritus), hair loss (positive alopecia)

psychiatric

positive paranoia, no suicidal thoughts (negative suicidal ideation)

all other systems negative

anything not specifically mentioned in the ROS are assumed to be negative

physical exam

doctors observations and examination of the patient

constitutional

emaciated, obese

eyes

PERRLA

HENT

oropharynx clear, normocephallic atraumatic

cardiovascular

regular rate and rhythm, 3/6 systolic ejection murmur

respiratory

chest clear to auscultation. no tracheal deviation

gastrointestinal

RUQ tenderness to palpation. No McBurney’s point tenderness

Genitourinary

penile swelling, cervical motion tenderness

musculoskeletal

2+ edema (swelling) right lower leg, right ROM limited secondary to pain

nervous

4/5 weakness to the right arm. Cranial Nerves II-XII intact

integumentary

4x3cm maculopapular rash, 4cm laceration

psychiatric

Suicidal Ideation. Flat affect.

X-ray

CT with contrast

CT without contrast

MRI

Ultrasound

examples of tests done in radiology

amylase

ANA

A1C: Hemoglobin A1c

B-hCG

BMP: basic metabolic panel

CBC: completed blood count

CKMB

CMP: completed metabolic panel

Electrolytes (electrolyte panel)

ESR (sedimentation rate)

Lipid Profile

LFT: liver function tests

PSA (prostate specific antigen)

Troponin

Urinalysis

Uric Acid

Urine Drug Screen

Examples of Lab Tests

Amylase

test for if you have symptoms of a pancreatic disorder, such as severe abdominal pain, fever, loss of appetite, or nausea.

ANA

This test helps to diagnose lupus and to rule out certain other autoimmune diseases

A1C: Hemoglobin A1c

Used to monitor a person’s diabetes and to aid in treatment decisions, this test is usually performed with the first diagnosis and then 2 to 4 times per year.

B-hCG

Typically performed to confirm and monitor pregnancy, or if symptoms suggest issues of concern. Urine sample is collected in the morning or a blood sample is drawn.

BMP: Basic Metabolic Panel

A group of 7-8 tests used as a screening tool to check for conditions like diabetes and kidney disease. You may be asked to fast for 10 to 12 hours prior to test.

CBC: Completed Blood Count

Determines general health and screens for disorders such as anemia or infections, as well as nutritional status and toxic substance exposure.

CKMB

This test measures the amount of creatine kinase(CK). An elevated CKMB can be indicative of a heart attack

CMP: Completed Metabolic Panel

This group of 14 tests gives your doctor information about the kidneys, liver, and electrolyte and acid/base balance, as well as of blood sugar and blood proteins.

Electrolytes (Electrolyte Panel)

This test can be requested as part of routine exam, and when your doctor suspects an excess or deficit of electrolytes (sodium or potassium) or an acid-base imbalance.

ESR (Sedimentation Rate)

The provider may order this test to determine the cause of inflammation, or to help

diagnose and follow the course of joint or muscle pain.

Lipid Profile

This group of tests can determine risk of coronary heart disease, and may be a good indicator of whether someone is likely to have a heart attack or stroke, as caused by blockage of blood vessels.

LFT: Liver Function Tests

This test can detect liver damage or disease. Multiple tests may be ordered at the same time, and may be used to detect hepatitis, or diagnose other liver-related conditions.

PSA (Prostate Specific Antigen)

This test is to screen for — and monitor — prostate cancer.

Troponin

This test measures the amount of troponin in the blood. When cardiac muscles are damaged in a heart attack, troponin levels increase.

Urinalysis

This standard test is usually performed on admission to a hospital or as part of an annual physical. It may also be done if you have symptoms relating to abdominal pain or blood in the urine. One to two ounces of urine are required.

Uric Acid

used to detect high levels of uric acid, or to monitor certain chemotherapy or radiation cancer therapies

Urine Drug Screen

Test for various legal and illicit drugs

MDM

section of the chart where the provider documents what the possible diagnoses they considered were, what medical interventions they deemed necessary to perform and why and how the patient responded to said medical interventions

Disposition

indicates where the patient will be going after leaving the ER. (discharge, admit, transfer)

discharge

Patients who have improved greatly under the treatment within the ED or can follow up with outpatient services are discharged.

admit

Patients who will need further care or intervention may be admitted to the hospital under the care of a hospitalist (Internal Medicine).

transfer

Patients who require specialized care, such as burn victims, often need to be transferred to a specialty facility