How to write SOAP notes.

SOAP notes are organized and narrative progress notes written in a logical approach to document patient’s problems. It addresses past medical and surgical histories, relevant family history, and social history.

SOAP notes follow these format:

S: - Subjective

O: - Objective

A: - Assessment

P: - Plan

SUBJECTIVE – This is the “why” a patient presents to the facility? It’s the complete description of patient’s symptoms. It could be short or long depending on patient’s situation or change in status. This is where a provider details what the patient narratives as his or her reason for the visit. It must contain pertinent information (negatives or positives) to enable a provider work up patient’s complaint. In other words, subjective section is the history of present illness.

“I go to the restroom four times last night.”

“Pt is requesting for medication refills.”

“Pt is here for 3 months follow up.”

A paragraph can have a summary of patient’s medical history and medications.

He has a history of diabetes. His medications include: Metformin 500mg BID, Insulin sliding scale

AN EXAMPLE

Mrs. Jones, a 40 year old female, presents to the clinic with complaint of epigastric pain increasing in intensity since last night. Patient stated that pain started after dinner with a burning sensation on her epigastric pain and then radiated to the right lower quadrant. Patient states she did not sleep well because of the pain.

She complained of nausea but no vomiting, diarrhea or constipation. She had a fried chicken for dinner and left okay until about two hours after eating.

OBJECTIVE – This section contains information obtained through physical examination, laboratory results, Vital signs, X-ray results, and current medications. You may include things you observed while interviewing a patient but do not include information you gathered from the patient.  

AN EXAMPLE

V/S: 120/80, 99.3, 75, WT 150, HT 5’10”

Gen: Oriented – General status, Person, Place, Time and situation

HEENT: No scalp lesions, Tympanic Membranes, Conjunctive,

Hearing – Grossly Normal, Ear Canals

External Ear Lesions, Ptosis, Eye Lesions,

Pupils = ERRLA, Dentition, Visual Acuity

Fundus, EOM, Turbinates, Nasal Lesions

Mouth Lesions, Tongue, Speech, Gums/Buccal Areas            

Neck: Trachea in Midline, Masses, Bruits, JVD, Thyroid

Heart: Rate, Rhythm, Murmur, Rubs, Clicks

            PMI – Location, Size, Force, Duration

            JVD – Carotid Artery pulses

Lungs: Clear to Auscultation, Wheezes, Rales, Rhonchi

Clear to Percussion Symmetrical Chest Movement

Abdomen: Soft, Non-tender, Non-distended, Organomegaly, Masses, Ascites, Rebound Tenderness, Bowel sounds, Bruits

DIAGNOSTICS:

WBC 10.5, PT/INR 2.0

MEDICATIONS:

Lisinopril 10mg 1 tab PO once daily

Lipitor 20mg 1 tab PO QHS

Tylenol 625mg q4h

ASSESSMENT: This is the diagnoses and strictly limited to that.

AN EXAMPLE

A new onset of epigastric abdominal pain. This is most likely secondary to gastritis because of the location and associated pain. A less likely possibility is constipation, given the intensity and location of the pain

PLAN: This is the plan and step necessary to address and treat patient’s condition(s). The plan to include the course of action.

AN EXAMPLE

1. Admit to Bed Tower

2. NPO

3. V/S: q6 h

4. Labs: CBC, WBC, U/A

5. Surgical Consult initiated

6. MEDS: Tylenol 625mg q4h