Nutritional Progress Notes

1
Nutritional Progress Notes
2
Objectives

• After this presentation, you will be able to
• State the descriptive words for the acronym SOAP
• Give a brief description of the meaning for each
  word in the acronym SOAP
• Write a progress SOAP progress note from a case
  study

3
What is a SOAP Note?

• Summary report of clients/patents condition
• Written in clients/patient's chart
• Acronym for
• S subjective
• O objective
• A assessment
• P plan

4
Pros and Cons of SOAP Charting

• PROS
• Common use by nutrition care professionals and
  other medical disciplines
• Taught in most dietetics education programs
• Easy to learn and utilize

• CONS
• Can encourage lengthy chart notes
• Some physicians are less likely to respond to
  this format than others
• Can downplay continued reevaluation of clients
  progress
• Emphasizes legitimacy of objective over
  subjective data

5
S Subjective

• Information provided/spoken by patient, family,
  or other person.
• Pertinent socioeconomic, cultural info
• Level of physical activity
• Significant nutritional history usual eating
  pattern, cooking, dining out
• Work schedule

6
O Objective

• Factual and reproducible observations.
• Diagnosis
• Height, age, weightand weight gain/loss patterns
• Lab data
• Clinical data (nausea, diarrhea)
• Diet order
• Medications
• Estimation of nutritional needs

7
A Assessment

• Summary of dietitian's professional nutrition
  diagnosis or clinical thoughts.
• Interpretation of patients status based on
  subjective and objective info
• Evaluation of nutritional history
• Assessment of laboratory data and medications
• Assessment of diet order
• Assessment of patients comprehension and
  motivation

8
P Plan

• Describes the scope of Treatment and contains
  the action plan and prognosis.
• Diagnostic studies needed
• Further lab work or lab data needed
• Medical nutrition therapy goals
• Education nutrition plans
• Recommendations for nutritional care
• Date for any follow-up

9
Sample SOAP Note

• Subjective
• S works second shift, eats two meals a day,
  before/after shift usually eats in fast food
  restaurants (fried foods, burgers, ice cream) for
  lunch and dinner. Does not add salt to foods.
  Takes blood pressure 2x/day. Activity Plays
  volley ball on weekends

10
Sample SOAP Note

• Objective
• O 34 y.o. female last menstrual period
  01/05/2006 iron level 12.3 history of
  hypertension x 2 years blood pressure 130/85
  for last four readings height 5ft. 3in
  weight 205 lb BMI36.

11
Sample SOAP Note

• Assessment
• A obese hemoglobin level normal excessive
  sodium intake (NI-5.10.2) related to frequent use
  of fast food meals as evidenced by diet history.
  Blood pressure high/normal. Low physical
  activity.

12
Sample SOAP Note

• Plan
• P Reviewed DASH diet. Identified foods to pack
  from home to eat during lunch/dinner. Discussed
  non-food rewards to purchase with money saved
  from not eating out when weight and B/P goals are
  reached. Encouraged more activity to facilitate
  weight loss. Next appointment 30 days from
  today.

13
Conclusion

• Not all the parts are used at every visit
• Complete sentences are not necessary
• Signature goes at end of last line
• Never leave a blank line between entries
• Never leave a half filled line. Draw a line to
  fill the line.

14
Lecture Quiz

• What does the acronym SOAP stand for and give a
  brief description of the meaning for each word.
• What medical professionals usually use SOAP
  notes?
• Name one advantage and one disadvantage to using
  SOAP progress notes.

15
Lecture Quiz

• Write a progress SOAP progress note using the
  following case study
• Your second appointment for the day is with a 25
  year old Chinese male. He states he was told by
  his doctor that his cholesterol is high and he
  should to eat better but he is confused as to
  how to do that. He hands you a paper with the
  following labs on it height 67 weight
  200 blood pressure 120/80 total cholesterol
  150 and LDL levels 160.