SOAP Note submissions assignment
SOAP Note submissions assignment
SOAP Note submissions assignment
In addition to Journal Entries, SOAP Note submissions are a way to reflect on your Practicum experiences and connect these experiences to your classroom experience. SOAP Notes, such as the ones required in this course, are often used in clinical settings to document patient care. Please refer to this week’s Learning Resources for guidance on writing SOAP Notes.
Select a patient who you examined during the last 3 weeks. With this patient in mind, address the following in a SOAP Note:
- Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent, as well as possible reasons for these discrepancies.
- Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
- Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
- Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
- Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
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Structure
The 4 headings of a SOAP note are Subjective, Objective, Assessment and Plan. Each heading is described below.
Subjective
This is the first heading of the SOAP note. Documentation under this heading comes from the “subjective” experiences, personal views or feelings of a patient or someone close to them. In the inpatient setting, interim information is included here. This section provides context for the Assessment and Plan.
Chief Complaint (CC)
The CC or presenting problem is reported by the patient. This can be a symptom, condition, previous diagnosis or another short statement that describes why the patient is presenting today. The CC is similar to the title of a paper, allowing the reader to get a sense of what the rest of the document will entail.
Examples: chest pain, decreased appetite, shortness of breath.
However, a patient may have multiple CC’s, and their first complaint may not be the most significant one. Thus, physicians should encourage patients to state all of their problems, while paying attention to detail to discover the most compelling problem. Identifying the main problem must occur to perform effective and efficient diagnosis.
History of Present Illness (HPI)
The HPI begins with a simple one line opening statement including the patient’s age, sex and reason for the visit.
Example: 47-year old female presenting with abdominal pain.
This is the section where the patient can elaborate on their chief complaint. An acronym often used to organize the HPI is termed “OLDCARTS”:
Onset: When did the CC begin?
Location: Where is the CC located?
Duration: How long has the CC been going on for?
Characterization: How does the patient describe the CC?
Alleviating and Aggravating factors: What makes the CC better? Worse?
Radiation: Does the CC move or stay in one location?
Temporal factor: Is the CC worse (or better) at a certain time of the day?
Severity: Using a scale of 1 to 10, 1 being the least, 10 being the worst, how does the patient rate the CC?
It is important for clinicians to focus on the quality and clarity of their patient’s notes, rather than include excessive detail.
History
Medical history: Pertinent current or past medical conditions
Surgical history: Try to include the year of the surgery and surgeon if possible.
Family history: Include pertinent family history. Avoid documenting the medical history of every person in the patient’s family.
Social History: An acronym that may be used here is HEADSS which stands for Home and Environment; Education, Employment, Eating; Activities; Drugs; Sexuality; and Suicide/Depression.
Review of Systems (ROS)
This is a system based list of questions that help uncover symptoms not otherwise mentioned by the patient.
General: Weight loss, decreased appetite
Gastrointestinal: Abdominal pain, hematochezia
Musculoskeletal: Toe pain, decreased right shoulder range of motion
Current Medications, Allergies
Current medications and allergies may be listed under the Subjective or Objective sections. However, it is important that with any medication documented, to include the medication name, dose, route, and how often.
Example: Motrin 600 mg orally every 4 to 6 hours for 5 days
Objective
This section documents the objective data from the patient encounter. This includes:
Vital signs
Physical exam findings
Laboratory data
Imaging results
Other diagnostic data
Recognition and review of the documentation of other clinicians.
A common mistake is distinguishing between symptoms and signs. Symptoms are the patient’s subjective description and should be documented under the subjective heading, while a sign is an objective finding related to the associated symptom reported by the patient. An example of this is a patient stating he has “stomach pain,” which is a symptom, documented under the subjective heading. Versus “abdominal tenderness to palpation,” an objective sign documented under the objective heading.
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