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How To Write A Good SOAP Note

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Tags: SOAP Notes Decision Tree, PICOT EBP, Nursing Informatics, PMHNP role, issues nurses faces, telehealth telemedicine, BSN MSN DNP, Nursing Care Plans

What is a SOAP Note?

A SOAP note is a document that contains detailed information about the patient. It is usually written in an organized manner with clearly identified components. Healthcare professionals use a SOAP note to document their patients’ medical histories as part of their medical records. A SOAP note provides a standard format that clinicians can use to present patients’ information in an organized manner. The document allows an easy review of client documents. The acronym “SOAP” has been generated based on the specific components of the document. It comprises five sections namely the subjective data, the objective data, assessment, and plan. Each section contains different types of information.

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The subjective section contains information that has verbally been presented by the patient concerning his or her illness. Under this section, the clinician gathers information about the onset of the current illness, the location of pain, type of pain, alleviating factors, the main source of the pain, and the patterns of associated symptoms. The objective section contains information that has been collected after the clinician has made an objective observation of the client. The information is considered objective because it comprises factors that can be seen, heard, or measured. Under this section, the practitioner usually documents the vital signs such as changes in body temperature, physical exam results, as well as the outcomes of diagnostic tests. The other part of a SOAP note is the assessment section. Under this section, the clinician documents the differential diagnosis as well as the primary diagnosis of the patient’s condition. The final section of the document is the ‘Plan.’ In this segment, the clinician outlines the specific interventions that will be implemented to address the patient’s problem. It may include additional tests that should be performed and the treatment options that should be prescribed and administered.

The main elements that are included in a  SOAP Note

The nurse should know how to write a good SOAP note that can be used to gain an insight into the patient’s problem. A SOAP note must contain four headings written as Subjective, Objective, Assessment, and Plan. The specific types of information that are to be included under this section include the Chief Complaint, History of Present Illness, the Patient’s Medical History, Review of Systems, as well as Current Medications and Allergies. As earlier mentioned, the specific details that are to be written under the objective section include; vital signs, laboratory data, physical exam findings, and imaging results. When documenting the assessment section, the clinician should synthesize the subjective and objective data and utilize it to summarize the patient’s case.  He or she should write differential diagnoses of the patient’s condition in order of importance. The primary diagnosis should then be selected from the list.  The plan section should be written clearly and concisely to help other clinicians understand what should be done next to address the patient’s problem. It should detail the specific tests required and their rationale, the therapy required, referrals, and an outline for patient education.

With a well-written SOAP note, the clinician can easily understand the patient’s problem and establish the primary diagnosis based on the subjective and the objective data. The clinician must be careful to maintain a high level of accuracy when writing a SOAP note. The reason is that the documentation of inaccurate data may harm the patient. Generally, a SOAP note is advantageous for healthcare professionals because it helps them to document the patient’s information in an organized manner that can easily inform a clinical decision.

Example of Acute Respiratory Symptoms and Diabetes SOAP Note;

Patient Initials: K. S.                 Age: 72 years old               Race: Korean      Gender: Male

SUBJECTIVE DATA:

Chief Complaint (CC): “I have a sore throat, Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx  a runny nose. I also have a small Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx foot.”

History of Present Illness (HPI): K. S. is a 72-year old Korean male who has visited the clinic unaccompanied. As reported by K. S., he has been experiencing sore throat, Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx his right foot. Additional symptoms include mild fever and sneezing. These symptoms began 2 days ago and Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx . The patient experiences Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx he is in hot weather. Sore Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx of 52 and he has been using Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx . Before Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx , K. S. reports that Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx a lot. These Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx use metformin. The patient’s symptoms cXxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx ;

Location: Nose, tXxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx , and toe.

Onset: 2 days ago for Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx t, frequent urination, Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx toe.

Characteristic/Quality: A sore Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx , and an ulcer on the toe of his right foot.

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Associated symptoms: Fever, Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx .

Timing: Symptoms are more severeXxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx the day.

Exacerbating or relieving factors: Cold weather exacerbates Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx .

Severity or quantity: 4/10 on the pain scale (headache).

Medications: K. S. is using metformin to Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx .

Allergies: No known Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx reported.

Past Medical History (PMH): Reports a positive diagnosis of Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx cold, and general body weakness. These conditions were Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx . K. S. was diagnosed with Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx using metformin.

Past Surgical History (PSH): Denies surgical history.

Sexual/Reproductive History: K. S. is sexually active and Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx children. He states tXxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx .

Personal/Social History: K.S. is a retired teacher and Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx farm activities. K. S. denies Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx use. He is a Christian who Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx . K. S. denies engaging in physical activities iXxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx . His diet Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx  Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx he was diagnosed with type-2 diabetes.

Immunization History: K. S. received Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx  Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx medical records.

Significant Family History: The patient’s father Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx complications. His mother had diabetes and sheXxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx any serious condition.

Review of Systems:

General: K. S. has recorded a slight rXxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx  Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx month. He feels Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx s fever.

HEENT:

Head: Denies physical head injury. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx .

Eyes: Reports a Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx .

Ears: Denies ear and hearing problems.

Nose: Has a runny nose Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx  Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx nasal congestion.

Throat: Reports a sore throat.

Neck: Denies Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx on.

Respiratory: Reports Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx  Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx cough.

Cardiovascular/Peripheral Vascular: Denies tightness of the chest.

Gastrointestinal: Denies Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx  pain.

Genitourinary: Reports frequent Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx  intake.

Musculoskeletal: Denies joint pain. Reports an ulXxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx .

Psychiatric: Denies changes Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx .

Skin: Denies skin itchiness, rashes, or redness.

Hematologic: Denies a history of blood-related disorders.

Endocrine: Denies Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx  Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx .

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OBJECTIVE DATA:

Physical Exam:

Vital signs: Body temperature: 37 degrees Celcius, weight=95.7 lb., Height=51 inches, respiratory rate=20.

General: K. S. is well-groomed, attentive, and Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx . Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx .

HEENT:

Head: Normocephalic with no evidence of physical injury. Hair evenly distributed all over the scalp.

Eyes: VXxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx pink.

Ears: Ear canal is clear. Both ears are sensitive to sound waves.

Nose: Nasal Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx nose.

Throat: Signs of redness in the throat. Buccal mucosa is moist and pink. K. S. coughs persistently on observation.

Neck:  Upright Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.

Lungs: Trouble Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx No wheezing.

Heart: No murmurs, no Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx .

Abdomen: No bowel sounds, Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx palpation.

Musculoskeletal: No evidence Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx ulcer on his big toe of the right foot.

Neurological: No evidence of numbness.

Skin: Skin appears dry, no rashes, no redness.

Lab tests, x-rays, and other procedures: Perform an x-rayXxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx  s. Perform throat culture to find other Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx (Mayo Clinic, 2021). Culture specimen Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx organismsXxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx level. Perform complete blood count test (CBC) to assess the concentrations of blood cells (Sullivan, 2019; Dains et al., 2016).

ASSESSMENT:

Differential diagnoses: Type 2 diabetesXxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx (Primary diagnosis).

: Acute sinusitis and type 2 diabetes

: Acute bronchitis and type 2 diabetes.

Rationale

The patient’s symptoms match those ofXxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx . Symptoms Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx  Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx foot (Goyal & Jialal, 2021). Symptoms that match those of common cold include a sore throat, Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx  Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx g, and fever (Pappas, 2018). Although the patient presents with nasal Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx due to the Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx tom for the disease (DeBoer & Kwon, 2021). Besides, aXxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx evidenced in the chest and the patient does not present with malaise despite the fact that he presents wXxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx y breathing (Singh et al., 2021).

PLAN:

Diagnostics:

  • Repeat A1C Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx , and glucose tolerance test tXxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx  Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx (Goyal & Jialal, 2021).
  • Observe Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx  Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx  old (Mayo Clinic, 2021).

Therapeutics:

Pharmacological treatment:

  • Prescribe clindamycin to treat diabetic foot ulcer. Advise the patient to continue using metformin as prescribed (Goyal & Jialal, 2021).
  • Prescribe Tylenol to relieve headache.
  • Prescribe decongestants to relieve nasal congestion and sneezing (Mayo Clinic, 2021).
  • Prescribe dextromethorphan to relieve acute cough (Pappas, 2018).

Non-pharmacological intervention:

  • Remove dead tissue from the ulcer (debridement) and clean the area (American Podiatric Medical Association, 2021).
  • Encourage the patient to take warm water to relieve nasal congestion (Mayo Clinic, 2021).

Patient education, health promotion, referrals, and follow-ups:

  • Educate the patient about Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx .
  • Educate the patient on Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx (Edelman et al., 2017).
  • Involve fXxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx f the patient.
  • Advice the patient to dress warmly Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx s, especially on the ulcerated area (American Podiatric Medical Association, 2021).
  • Emphasize on Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx  Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx eating more fruits, milk, and vegetables (Goyal & Jialal, 2021).
  • Refer the patient to a physiXxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx activities.
  • Ask the patient to contact the clinic in case proXxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx r. He should aXxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx evaluation (Treas et al., 2018).

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