SOAP Notes

SOAP NOTE FORMAT

Purpose of the Problem Oriented Medical Record

  1. To improve communication among all those caring for the patient.
  2. 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 patient’s 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:

  1. observation of the patient
  2. Physical examination
  3. Laboratory results
  4. 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:

  1. A plan for collecting further information like blood tests or X-rays.
  2. A plan for initial treatment with specific procedures or medications.
  3. A plan for educating the patient
  4. Referral and / or consultations
  5. Plan for follow up.

SOAP NOTE FORMAT IN DETAIL:

S: SUBJECTIVE - what the patient tells you.

  1. Chief Complaint (CC) - The patient’s reason for coming to the clinic today. The CC is usually a single statement. Example: CC/sore throat.
  2. Associated symptoms - ex: fever, muscle aches, swollen glands in neck, hoarseness.
  3. Duration of symptoms - ex: times 3 days.
  4. Any new symptoms which have appeared or prior symptoms noted. Ex: chills 3 days ago associated with runny nose, which cleared.
  5. Anything that makes the symptoms better or worse, aggravates or relieves the problem. Ex: going up stairs aggravates the pain, better with rest.
  6. Frequency of symptoms - ex: constant pain, increasing with swallowing, headaches every other day.
  7. Remedies tried already - ex: ASA, salt water gargles - effective or ineffective.
  8. Antecedent events - ex: exposure to child with strep throat. Others in barracks with same problems.
  9. Severity of symptoms - particularly pain (rate on a scale of 1 - 10). Quality of pain - burning, aching.
  10. Location of symptoms - ex: pain in back of throat, radiating to ears.
  11. Significant negatives - ex: no cough, ear pain, post nasal drip
  12. 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.
  13. Allergies - If the patient is allergic to something, note both the allergy and the effect when the patient is exposed ex: penicillin allergy - hives.
  14. Immunization status (Tet., Tox., MMR, etc.) Should always check for tetanus immunity if patient has a wound. Check the shot record if possible.
  15. 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
  1. 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.
  2. 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

  1. Further diagnostic studies needed. Ex: Throat Culture, Urine Culture, Chest X-ray, and CBC.
  2. Therapeutic regimen including medications given, treatments prescribed. Specify dosage, how they are to be taken, and how often.
  3. 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. Patient’s response to education i.e. states understanding; questions answered or needs further education.
  4. 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.

Hospital Corpsman Sickcall Screeners Handbook

Naval Hospital, Great Lakes

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