PROGRESS NOTE (SOAP Notes)

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PROGRESS NOTE(SOAP Notes)

• H.A.Soleimani MD
• Gastroenterologist

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PROGRESS NOTE (SOAP Notes (

• The medical student should be the person most
  intimately aware of the patient's status, it is
  appropriate that he or she be given the
  responsibility of writing the note each day.

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PROGRESS NOTE (SOAP Notes (

• One of the most important documents in the
  medical record is the daily progress note

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PROGRESS NOTE (SOAP Notes (

• The progress note
• Reflect what transpired during the previous 24
  hours
• Updates a patient's clinical course each day
• Summarizes the ward team's ongoing assessment and
  plan.

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PROGRESS NOTE (SOAP Notes (

• Progressnote include a directed or focal
  examination, and plans for further evaluation.

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Use the SOAP format

• Subjective
• Objective
• Assessment
• Plan

• SSubjective

OObjective
AAssessment
PPlan
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Progress note

• Uses
• 1,Daily evaluation of a hospitalized
  patient
• 2,Return visit in outpatient clinic

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Progress note

• Subjective (Focused history)
• 1. Information you have learned from the
  patient or people caring for the patient

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SUBJECTIVE SUMMARY

• The note begins with a statement of the patient's
  own (subjective) assessment of his condition.

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SUBJECTIVE SUMMARY

• The subjective portion should include some of the
  patients or parents' own words.

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OBJECTIVE SUMMARY

• 1 -Vital signs
• 2-The patient's general appearance
• 3-Physical exam findings
• 4- Any diagnostic test results (Laboratory and
  imaging..)

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OBJECTIVE SUMMARY

• VITAL SIGNS
• Blood Presure
• Pulse Rate
• Respiration Rate
• Temperature
• (Weight, Pain, xygen Saturation? )

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OBJECTIVE SUMMARY

• The patient's general appearance should be noted
  after vital signs.

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OBJECTIVE SUMMARY

• PHYSICAL FINDINGS An directed physical
  examination should be recorded with all pertinent
  areas described.

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OBJECTIVE SUMMARY

• Laboratory data Although one will often wish to
  mention certain laboratory data in the
  assessment, there is no need to list all of the
  results.

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PROGRESS NOTE (SOAP Notes (

• Because the progress note is focused on
  "progress,' the assessment and plan section
  includes only problems that are being addressed
  during the hospitalization.

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ASSESSMENT

• AssessmentProvide your working diagnosis and
  mention the state of the patient

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ASSESSMENT

• Identify the major or primary assessment
  supported by the patient database and any other
  associated assessments.

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ASSESSMENT

• 1.What do you feel is the patients differential
  diagnosis and why?
• 2.Organized by problem or organ system

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ASSESSMENT

• Every day problem list with Every day
  differential diagnosis for each problem

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PLAN

• A separate plan should be developed for each
  assessment.

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PLAN

• Each plan should be divided into
  1.Diagnostics(Lab .x.ray..)
• 2.Therapeutic
• 3.Patient Education
• 4.Health Promotion
• Strategies

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PLAN

• For each problem what diagnostic testing will
  you order?

How will you treat each problem or diseases?
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PLAN

• Action planned for each problem
• AP( assessment and plan)

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PROGRESS NOTE (SOAP Notes (

• Progress note maybe quite brief. It does not need
  to be crafted in fall sentences as long as it is
  easily comprehensible.

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PROGRESS NOTE (SOAP Notes (

• It is also important to remember that the
  progress note, like the oral and written
  presentations, is part of the student's education
  and should be reviewed with the intern, resident,
  or attending.

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PROGRESS NOTE (SOAP Notes (

• The date, time, title, are essential
• USE BLACK INK
• SIGN AND write YOUR NAME on any chart notes

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EXAMPLE OF PROGRESS NOTE

• (SOAP Notes)

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EXAMPLE OF PROGRESS NOTE

• SUBJECTIVE
• SUBJECTIVE
• SUBJECTIVE

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PROGRESS NOTE (SOAP Notes

• Mr. Hamedi is an 84 year old man who comes to
  the hospital 7 day ago for angiography and today
  he have worsening leg swelling. The swelling
  started 3 days ago in his ankles and has
  progressively moved toward his groin.

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PROGRESS NOTE (SOAP Notes

• He also feels short of breath. For the past two
  days he cant walk without resting halfway. He
  has difficulty breathing when lying in bed.

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EXAMPLE OF PROGRESS NOTE

• OBJECTIVE
• OBJECTIVE
• OBJECTIVE

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PROGRESS NOTE (SOAP Notes)

• 1. Vital signs BP 120/72, HR 68,
• RR 20, T 36
• 2. Chest crackles 1/3 up bilaterally.

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PROGRESS NOTE (SOAP Notes)

• Extremities No erythema or tenderness.
• 2 pitting edema bilaterally to his knees.

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PROGRESS NOTE (SOAP Notes)

• 3.Cardiac Regular rate and rhythm, normal S1
  and S2, S3 is present, No murmur

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PROGRESS NOTE (SOAP Notes)

• Abdomen Normoactive bowel sounds,
• soft, non-tender,
• non-distended,
• no hepatomegaly
• or splenomegaly

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PROGRESS NOTE (SOAP Notes)

• Labs visit
• Sodium 125 (135 -145)
• Potassium 3.6 (3.5 5.1)
• BUN 40 (10 20)
• Creatinine1.5 (0.6 1.3)

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EXAMPLE OF PROGRESS NOTE

• ASSESSMENT
• ASSESSMENT
• ASSESSMENT

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PROGRESS NOTE (SOAP Notes)
Problem

• Shortness of Breath
• New dyspnea on exertion
• S3 crackles and edema

ASSESSMENT
1.Congestive heart failure or new angina
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PROGRESS NOTE (SOAP Notes)
Problem

• Edema

ASSESSMENT
1.Congestive heart failure or new angina
2.Nephrotic syndrome
3.hypothyroidism
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PROGRESS NOTE (SOAP Notes)

• No suggestion of
• pure pulmonary disease

No suggestion of Hypertension Blood presure is
well controlled and is probably not contributing
to his presenting complaints.
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EXAMPLE OF PROGRESS NOTE

• PLAN
• PLAN
• PLAN

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Congestive heart failure or new angina

• We will order an EKG right now to assess
• cardiac rhythm and acute injury.

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Congestive heart failure or new angina

• We will also send him for an echocardiogram to
  measure his cardiac function.

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Nephrotic syndrome

• We will check a urinalysis to rule out the
• proteinuria of nephrotic syndrome

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Hypothyroidism

• Check a thyroid stimulating hormone level to
  evaluate his thyroid function.

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Hypertension

• No changes are needed in his blood pressure
  medication.

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