SOAP Notes

1
SOAP Notes

• Health Care Documentation
• Heather Peterson
• October 10, 2005

2
Documentation

• Cases for oral health care
• Interview and Counsel patients
• Write a SOAP note about the interaction
• Can use SOAP checklist on Blackboard
• Present to class

3
Header

• Patient name
• Age
• Chief complaint
• Allergies
• Can see these as a header at the beginning of the
  SOAP note or within the S and O parts.

4
Subjective

• Written in full sentences, paragraph form.
• Identify patient and give brief description of
  encounter
• Mrs. Johnson, a 47 yo woman, presents to the
  pharmacy with a question about canker sores.
• State patients complaints
• One sentence in patients words
• I keep getting these painful white dots in my
  mouth. How do I treat them?
• 8 attributes
• Histories if pertinent PMH, FH, SH

5
Subjective example

• Sylvia York DOB 1/27/76
• CC headache NKDA
• S-Sylvia York, a 27 year old female presents to
  the pharmacy asking about treatments for a
  headache. She has throbbing pain on the right
  side of her head, accompanied by some nausea,
  photophobia and phonophobia. She rates the pain 7
  out of 10. She has been diagnosed with migraines
  3 years ago but didnt start having them often
  until a few months ago. She has had 3 in the
  past 2 months. She usually takes 2 Tylenol PM
  and sleeps through the pain in a dark, quiet
  room. The headaches typically last 4 to 6 hours.
  She cannot do that this time because she
  recently started taking night classes and has to
  stay up tonight to study for a test. Sylvia is
  currently taking Ortho Tri-Cyclen. She has been
  taking samples for the past 4 months given to her
  by her doctor. She does not take any other Rx
  drugs, OTC drugs or supplements. She does not
  smoke or drink alcohol. She drinks 2-3 caffeine
  drinks a week.

6
Objective

• Written in list format typically.
• Allergies
• Medications (Rx, OTC, supplements, herbal)
• Physical exam vital signs, any physical
  assessment (describe patients appearance)
• Patient has a flat, oval ulcer with erythematous
  tissue around it on the right inner cheek.
• Pertinent labs, test results (not usually in
  community setting)

7
Objective example

• O Sylvia appears healthy, but somewhat stressed
  and uncomfortable
• Medical dx Allergies
• Migraines NKDA
• Medications
• Ortho Tri-Cyclen Lo4/30/02 to 5/25/05
• Ortho Tri-Cyclen samples since 05/25/05
• B.P 116/74 mm Hg

8
Assessment

• Written in full sentences, paragraph form.
• All issues in S O addressed in A
• Supporting data for assessment should be found in
  S O
• Organize, prioritize by disease state, complaint,
  drug related problem
• State the problem, disease, etc justify
  decision by discussing other options and how you
  reached conclusion.
• Goals for treatment
• Justify recommendations discuss other options
  and why option chosen
• Safety, tolerability, efficacy/evidence, price,
  simplicity

9
Assessment Example

• A . Based on the location of the headache, the
  severity of the pain and the associated sx it is
  likely the patient has a migraine HA. Tension HA
  was ruled out because of the location and
  severity of the HA. Rebound HA was ruled out
  because the patient does not take analgesics
  regularly or drink caffeine regularly. An
  increase in the frequency of the headaches is
  associated with a change in oral contraceptives.
  The newer formulation, Ortho Tri Cyclen, has a
  higher dose of estradiol, which has been
  documented to increase the frequency and severity
  of migraine headaches. The goals of treatment
  are to alleviate the acute pain, restore normal
  functioning so the patient can study, and prevent
  relapse. It is recommended she speak with her
  PCP about her increase in migraines since
  switching to Ortho Tri Cyclen. Extra Strength
  Tylenol (acetaminophen 500 mg) 2 q4-6h prn pain
  is recommended to treat the current migraine.
  The patient has taken Tylenol PM (acetaminophen
  500 mg and diphenhydramine 25 mg) in the past and
  said it worked. Extra Strength Tylenol has the
  same analgesic without the antihistamine,
  diphenhydramine which may make her drowsy. Other
  OTC analgesics may be effective. Since she does
  not drink alcohol or have a history of liver
  disease, she does not have any contraindications
  to acetaminophen. Successful use of
  acetaminophen of the past makes it a reasonable
  initial choice for self-treatment.

10
Plan

• Written in brief sentences, concise and complete.
• Provides actions to be taken based on A, includes
  treatment, monitoring, education.
• Medication recommendation drug, dose, route,
  frequency, duration.
• Monitoring efficacy and toxicity parameters,
  timeframe for effect, precautions, SE.
• Follow-up

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Plan example

• P Sylvia is to take 1-2 acetaminophen 500 mg
  tablet every 4-6 hours as needed for migraine HA
  pain, NTE 4000 mg (8 tablets) in 24 hours. The
  medication should take effect within 1 hour. She
  is not to drink alcohol while taking the
  medication or take any other acetaminophen
  containing products during this time. It is also
  recommended that she use an ice pack on the
  location of the pain and study in a quiet room.
  In the future she should keep a HA diary to try
  to identify migraine triggers. She is to meet
  with her PCP to discuss the increase incidents of
  migraines in the past few months. She will call
  the pharmacy to report on the efficacy of the
  chosen therapy..

12
Closing

• Sign name and title
• Date

13
All sections

• Written in ink (black or blue)
• Abbreviations and symbols can be used
• Mistakes are crossed out with a single strike and
  initialed.
• Legal document!
• Never write offensive or accusatory statements
• Grammer and spellling

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Clinic SOAP example

• Patient Name Robert Dreg DOB 09/17/1967
• Record No. D-679dk978
• Date 12/4/99
• SPain in left hip x 3 months worse when walking
  or doing exercise. NKDA.
• OWt. 195 lb, Ht. 5'5'', normal ROM both hips, no
  swelling or redness.
• APossible osteoarthritis R/O rheumatoid
  arthritis
• Pbloodworksed rate, rheumatoid factor, x ray L
  hip PA and lateral ibuprofen 600 mg t.i.d po
  recheck 2 months.
• --------------------------------------------------
  ----- Bob Ridman, CCMA
• Brenda D. Fleiss, MD