SOAP info

What does SOAP stand for?

Subjective, Objective, Assessment, and Plan

What is a SOAP note?

Method of documentation for providers of the patient’s encounter in the emergency dept. that day

All electronically recoded in the patients electronic medical record/electronic health record

Subjective component of the EMR/EHR

any info that comes from the patient or their family (anything that pertains to why they are at the ED today)

Objective component of the EMR/EHR

Any information that comes from the provider (like vital signs, test results, etc).

Medical decision making is major part: everything that the provider does and utilizes to find out what is wrong with the patient

Assessment component of the EMR/EHR

diagnosis of the patients condition

Plan component of the EMR/EHR

what the provider plans to do with the patient (admit or discharge)

Subjective

—>

Chief complaint

2-3 word summary of why the patient has come into the ER (ex. headache, cough, back pain)

HPI

stands for history of patients illness

section of the note where the scribe documents the patients story of why they came to the ED from their perspective , along with any medical history

Elements of an HPI (COLD CARS)

Context -

Onset - when the patient experiences signs or symptoms

Location/radiation - rad. refers to whether or not the symptoms/pain move anywhere else regularly

Duration

Character - characteristics of the chief complaint

Alleviating/aggravating factors - things patient has done to alleviate symptoms

Related symptoms

Severity

Histories

PMHx - prior medical history:

PSHx - prior surgical history

SHx - social history (environmental factors like smoking, living sit.)

FHx - family history

Reviews of Symptoms (ROS)

covers all body symptoms by asking yes or no questions and documented with wither positive or negative

ex) respiratory: Shortness of Breath (Positive dyspnea), no blueness of the skin (Negative cyanosis)

Objective

—>

Physical exam (PEx)

doctors observations and examinations of the patient

ex. Integumentary: 4x3cm maculopapular rash, 4cm laceration

similar to ROS but this is objective so can be confirmed by the doctor

Labs and radiology

Rad: tests and scans such as X-rays and MRIs to gather more info

Labs: extracting bodily fluid and sending it in for a chemical test

Type of labs you can order

Amylase: symptoms of pancreatic disorder

ANA: diagnose lupus, rule out other autoimmune diseases

A1C: diabetes (hemoglobin act)

B-hCG: monitor pregnancy

BMP: basic metabolic panel, 7-8 tests to check for things like diabetes or kidney disease (fasting)

CBC: completed blood count, screens for anemia, etc.

CKMB: measures creatine kinase

CMP: completed metabolic panel (14 tests)

Electrolytes

ESR: determine cause of inflammation, or joint/muscle pain

Lipid profile: determine risk of heart disease

LFT: liver function tests

PSA: prostate specific antigen, prostate cancer

Tropin: amount of troponin in blood

Urinalysis: admonial pain or blood in urine

Uric acid: levels of uric acid

Urine drug screen

Medical decision making (MDM)

consists of differential diagnosis (DDx) along with explanation for why each diagnoses were or were not in final diagnoses

Assessment

—>

Diagnosis

information complied to make decision. Ranked in order of most relevant, even if not likely the true diagnosis it is still recorded

Plan

—>

Disposition

where patient will be going after leaving ER

Discharge (improved), admit (need further care), transfer

Treatment plan, follow u[, and education

if any home meds need to be taken, given instructions

instructed to follow up

provide educational materials in cases where new diagnosis were made