SOAP

scribeology SOAP notes

SOAP abbrevation

Subjective, Objective, Assessment, and Plan

S: chief complaint

two or three word summary of primary reason the patient has come into the er

S: example of chief complaint

headache, cough, back pain, and chest pain

S: HPI

history of present illness; why the patient came to ED. from patient perspective, including why they came and any pertinent medical history

Elements of HPI

location/radition

context

duration

onset

character

related symptoms

alleviating/aggravating factors

severity

HPI: Context

what was going on when the patient started experiencing these symptoms

HPI: Onset

when the patient experiences signs or symptoms

not the point in time the symptoms started, but when during the day that they present

HPI: Location/radiation

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

radiation refers to whether or not the pain or symptoms move anywhere regularly

HPI: related signs and symptoms

Things patient has done to try and alleviate signs or symptoms

things tha tmake the symptoms better or worse

HPI: character

distinguishes the characteristics of the chief complaint or signs or symptoms and is usually an adjective (ex. throbbing, shooting, pounding or crushing)

HPI: duration

length of time that patient’s signs and symptoms exist (ie intermittent chest pain for two hours, duration is two hours)

HPI: COLD CARS

Context, Onset, Location/Radiation, Duration

Character, Alleviating/Aggravating Factors, Related Symptoms, Severity

S: Histories

provide a picture of the px medical, social, and family history. aids in diagnosis and px general state of being

S: PMHx

Prior medical history, any previous diagnosis that the patient may have. obtained through hospital records, charts, summaries, or directly from the patient

S: PSHx

Prior surgical history, any previous surgeries that the patient has had performed. often obtained through hospital records, charts and summaries, or directly from patient

S: SHx/SocHx

Social history; variety of environmental factors that can affect a patients condition. may include smoking status, alcohol usage, current marital status, and current living situation.
For children, it can also includes parent’s marital status, parent’s occupation, and whether or not the child is in daycare currently

Obtain through direct interviewing the patient

S: FHx

Family History; any diagnoses that patient immediate family may have been diagnosed with in the past. This primarily concerned with first degree relatives (parents, siblings, children) as many diseases have a genetic component.

Obtained through interviewing the patient or through previously recorded.

S: ROS, Review of Systems

ROS briefly covers all body systems by asking yes or no questions. Answered as positive or negative. Includes symptoms from the HPI, and every symptom that the patient is experiencing at the time of examination

ROS findings examples: Constitutional

Positive fever, feeling unwell (positive malaise)

ROS findings examples: Eyes

Sensitivity to light (positive photophobia), negative eye pain

ROS findings examples: HENT

Head, Ears, Nose, Throat

Positive sore throat, no runny nose (negative rhinorrhea)

ROS findings examples: Cardiovascular

Negative chest pain, irregular heartrate (positive palpitations)

ROS findings examples: Respiratory

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

ROS findings examples: Gastrointestinal

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

ROS findings examples: Genitourinary

Painful urination (positive dysuria), no blood in the urine (Negative hematuria)

ROS findings examples: Musculoskeletal

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

ROS findings examples: Nervous

Positive weakness, Negative facial droop

ROS findings examples: Skin

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

ROS findings examples: Psychiatric

Positive paranoia, No suicidal thoughts (negative suicidal ideation)

“All other systems negative”

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

Objective: PEx

Physical exam; based on doctors observations and examination of the patient. performed during or after interviewing patient.

varies on the doctor, patients chief complaint, and cooperation of patient

organized using itemized body systems

Unlike ROS, is objective aka information directly verified by the doctor

O: Diff between ROS and PEx

many findings may appear in both ROS and PEx. ROS is subjective and PEx is objective information

ex. if patient says they vomited 4 times that day, you record in the ROS. if they are vomiting in the room when interviewed, that is recorded as PEx

O: Labs and Radiology

scans that the physician may order to gather more info. ex. x-ray, CT with/without contrast, MRI, ultrasound

O: Amylase

request if symptoms of a pancreatic disorder, such as severe abdominal pain, fever, loss of appetite, or nausea

O: ANA

helps diagnose lupus and rule out certain other autoimmune diseases

O: A1C: Hemoglobin A1c

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

O: B-hCG

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.

O: BMP; Basic Metabolic Panel

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

O: 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

O: CKMB

measures the amount of creatine kinase (CK), an elevated CKMB can be indicative of a heart attack

O: 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

O: Electrolyte Panel

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

O: 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

O: Lipid Profile

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

O: LFT; Liver Function Tests

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

O: PSA; Prostate Specific Antigen

screened for, and monitor, prostate cancer

O: Troponin

measures the amount of troponin in the blood, when cardiac muscles are damaged in a heart attack, troponin levels increase

O: Urinanalysis

usually performed on admission to a hospital or as part of an annual physical. 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

O: Uric Acid

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

O: Urine Drug Screen

Test for various legal and illicit drugs

O: MDM

medical decision making; 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

Consists of DDx, Differential Diagnosis and explanation for each were or were not part of the final diagnosis

ED course: patients response to treatment, accompanied with a time stamp (ex 1455: patient given Zofran for intense nausea)

Assessment: Diagnosis

provider makes their decision on diagnosis. may have multiple causes that are ranked in order of most relevant

Plan: Disposition

indicates where the patient will be going after leaving the ER 3 categories; Discharge, Admit, Transfer, (and elopement, or escape w/out telling)

P: Discharge

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

P: Admit

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

P: Transfer

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

P: Treatment plan

if there are any home medications of treatments the patients should continue with, the plan will list them out along with the route of instructions. may also take the form of physical intervention, such as leg elevation, ice, or heat

EX. Take 1 amoxicillin TID (three times daily) for 10 days OR Keep legs elevated at night. apply pressure stockings every morning

P: Follow up

patient will be instructed to follow up with either a specialist or their PCP.

P: Patient education

depending on situation, patients may be provided with educational materials, particularly in cases where a new diagnosis was made. another common educational material is smoking cessation information