Intrduction to SOAP Notes

SOAP Notes

Widely utilized medical documentation format to organize information

What does SOAP stand for?

Subjective

Objective

Assessment

Plan

How to correct errors

Write in pen

Do not use white out

Cross out mistakes with one line (+initial and date)

Subjective

Information provided by patient or guardian

What is included in Subjective?

Cheif complaint

Introductory statement

HPI or history of present illness (includes 7 factors)

Any pertinent background information (past medical history, personal/social history, family history, review of systems)

Chief complaint

The primary symptom(s) and duration

Introductory statement

The first sentence of the HPI

What is included in the introductory statement?

Patient Name

Age

Gender

Ethnicity (inclusion depends on provider)

Pertinent PMHx

Chief complaint with duration

History of present illness (HPI)

The narrative story of the chief complaint

Utilizes the 7 factors

Chronology

The story of the chief complaint

How has it changed or developed over time

Setting

Where was the patient at the onset of symptoms

What was the patient doing at time of onset of symptoms

Location

Where is the symptom located on the patient’s body

Quality

How would the patient describe the symptom

Quantity

Regarding a numeric value to the complaint

Pain scale (1-10)

Giving a numeric value to conditions that can be measured

Aggravating/Alleviating factors

What makes the symptoms worse?

What makes the symptoms better?

Associated manifestations

Positive symptoms → what else is patient complaining of

Pertinent negatives → symptoms associated with chief complaint that the patient denies (aids in DDx)

Pertinent background information

Any information that is pertinent to the chief complaint

What is included in pertinent background information?

PMHx → illnesses/injuries/hospitalizations

Personal or social history → tobacco, alcohol, illicit drug use; travel or occupational history

Family history → any medical problems that run in the family

Review of systems (ROS) → associated manifestations

Allergies (subjective)

Include drug, latex, food, or environmental allergies

Always include the reaction

What does NKDA stand for?

No known drug allergy

Medications (subjective)

Use a standard format to document medications

Name, strength, dose, route, frequency, indication

Last normal menstrual period (LNMP) (subjective)

Documented on premenopausal women

Want to know if patient is pregnant or not

Objective

Information found from physical exam or diagnostic testing

What is included in Objective?

Vital signs

General statement

Problem specific physical exam

Diagnostic studies

Vital signs

Temperature, pulse, respiration, BP, height, weight, BMI, pulse ox

What does NAD stand for?

No apparent distress

Diagnostic studies (objective)

Include a list of any studies and results that were reviewed with patient at appointment

Includes any testing completed at time of visit with results

Assessment

What is wrong with the patient

What is included in Assessment?

Primary diagnosis

Secondary diagnosis

Primary diagnosis

The acute diagnosis based off the patient’s symptoms and signs

Includes appropriate R/O or DDx

Can be more than one primary diagnosis

Can be a symptom if the diagnosis is not determined

Secondary diagnosis

Chronic medical conditions already diagnosed

Plan

How are we going to treat or manage the diagnosis

What is included in Plan?

Diagnostic studies

Pharmacological treatment

Nonpharmacological treatment

Patient education

Follow-up

Diagnostic studies (plan)

Testing ordered at time of visit

List each test on a separate line

For specialized tests → need to indicate the reason for ordering

Pharmacological treatment

Medication prescribed for patient

OTC medications recommended for patient

Nonpharmacological treatment

Any other recommendations for patient that are not medications

Patient education

Any additional information given to the patient

Include information regarding medication side effect

Symptoms or signs that warrant evaluation in ER

Follow-up

When should the patient return to clinic (RTC)

RTC prn (return to clinic as needed)