Hospital Corpsman Sickcall Screener's Handbook
BUMEDINST 6550:9A
Naval Hospital Great Lakes
1999
SOAP Notes
SOAP NOTE FORMAT
Purpose of the Problem Oriented Medical Record
-
To improve communication among all those caring for the patient.
-
To display the assessment, problems and plans in an organized format to facilitate the care of the patient and for use in record review and quality control
S: SUBJECTIVE DATA:
Presents the problem from the patients point of view - how he feels. It may include the chief complaint present illness, past history. Current medications, diet and appetite, and allergies.
O. OBJECTIVE DATA
This is a record of the physical examination and includes the specific objective and reproducible findings gathered by:
-
observation of the patient
-
Physical examination
-
Laboratory results
-
x-rays
A. ASSESSMENT:
This is a short tentative working diagnosis for each problem.
P: PLAN:
This describes your plans for the care and management of each problem. What are you going to do to treat the patient? It may include one or all of the following:
-
A plan for collecting further information like blood tests or X-rays.
-
A plan for initial treatment with specific procedures or medications.
-
A plan for educating the patient
-
Referral and / or consultations
-
Plan for follow up.
SOAP NOTE FORMAT IN DETAIL:
S: SUBJECTIVE - what the patient tells you.
-
Chief Complaint (CC) - The patients reason for coming to the clinic today. The CC is usually a single statement. Example: CC/sore throat.
-
Associated symptoms - ex: fever, muscle aches, swollen glands in neck, hoarseness.
-
Duration of symptoms - ex: times 3 days.
-
Any new symptoms which have appeared or prior symptoms noted. Ex: chills 3 days ago associated with runny nose, which cleared.
-
Anything that makes the symptoms better or worse, aggravates or relieves the problem. Ex: going up stairs aggravates the pain, better with rest.
-
Frequency of symptoms - ex: constant pain, increasing with swallowing, headaches every other day.
-
Remedies tried already - ex: ASA, salt water gargles - effective or ineffective.
-
Antecedent events - ex: exposure to child with strep throat. Others in barracks with same problems.
-
Severity of symptoms - particularly pain (rate on a scale of 1 - 10). Quality of pain - burning, aching.
-
Location of symptoms - ex: pain in back of throat, radiating to ears.
-
Significant negatives - ex: no cough, ear pain, post nasal drip
-
Medications being taken currently - VERY IMPORTANT, especially for women. Always ask if they are on the pill as many medications are affected. Pregnancy may also be a consideration for treatment.
-
Allergies - If the patient is allergic to something, note both the allergy and the effect when the patient is exposed ex: penicillin allergy - hives.
-
Immunization status (Tet., Tox., MMR, etc.) Should always check for tetanus immunity if patient has a wound. Check the shot record if possible. -
Serious - medical history - ex: surgeries, history of rheumatic fever, etc review the chart!
O: OBJECTIVE - what you observe. Consists of two parts: physical findings and lab/ X-ray
-
Physical findings This should begin with your impression of the patient, what he looks like - his general appearance Is he alert and orientated or in any apparent distress? Look for any signs of alcohol or drug abuse. Then begin your complete physical examination of the patient. If symptoms are restricted to a specific body system or region, a more limited examination may be appropriate. Document only what you carefully examine and only the things that are pertinent.
Ex Pt. is alert and oriented x 3 no apparent distress.
ears - TMs are pearly, Nose congested, Throat red, with pustular exudate. Neg. monospot.
Ex Pt is alert and oriented x 3, with alcohol noted on breath.
Exam is essentially normal, ENT clear with mildly dry mucus membranes. Neck supple. Lungs are clear. Heart RRR. Abdomen soft nontender, neg. rebound. Normal bowel sounds.
-
STAT laboratory and X-ray results may be important in making the diagnosis.
A.: ASSESSMENT - This is where you think through the results of the history and physical examination. It calls for your interpretation and evaluation of the problem, the data, possible implications and the prognosis
Ex Pharyngitis, R/O strep vs. viral syndrome, R/O mononucleosis.
P: PLAN
-
Further diagnostic studies needed. Ex: Throat Culture, Urine Culture, Chest X-ray, and CBC.
-
Therapeutic regimen including medications given, treatments prescribed. Specify dosage, how they are to be taken, and how often.
-
Patient education: What the patient has been told about his sore throat what he should know and understand about his medications and therapy, as well as self care for the future. Note any educational printed material given. Patients response to education i.e. states understanding; questions answered or needs further education.
-
Disposition - SIQ, home, or back to limited or full duty. Follow-up must be specified.
Every SOAP note should include what arrangements were made for follow-up.
|
|
Approved for public release;
Distribution is unlimited.
The listing of any non-Federal product in this CD is not an endorsement of the
product itself, but simply an acknowledgement of the source.
Bureau of Medicine and Surgery
Department of the Navy
2300 E Street NW
Washington, D.C
20372-5300 |
Operational Medicine
Health Care in Military Settings
CAPT Michael John Hughey, MC, USNR
NAVMED P-5139
January 1, 2001 |
United States Special Operations
Command
7701 Tampa Point Blvd.
MacDill AFB, Florida
33621-5323 |
*This web version is provided by
The Brookside Associates Medical Education Division. It contains
original contents from the official US Navy NAVMED P-5139, but has been
reformatted for web access and includes advertising and links that were not
present in the original version. This web version has not been approved by the
Department of the Navy or the Department of Defense. The presence of any
advertising on these pages does not constitute an endorsement of that product or
service by either the US Department of Defense or the Brookside Associates. The
Brookside Associates is a private organization, not affiliated with the United
States Department of Defense.
Contact Us · Other
Brookside Products
|
Operational Medicine 2001
Contents
|
|
FMST Student Manual Multimedia CD
30 Operational Medicine Textbooks/Manuals
30 Operational Medicine Videos
"Just in Time" Initial and Refresher Training
Durable Field-Deployable Storage Case |
|