Hello. Welcome back. Today we're going to talk about SOAP notes. This is just the basic introduction to SOAP notes for those interested in or about to work in a health care setting. The SOAP note is really used for documentation and communication. We document an interaction with the patient so that we have a record of what happened. That record then becomes part of their permanent medical record. We also document to communicate with our future self and other health care team members that might need to know what's going on with the patient. SOAP notes are used across many disciples within the health services. The information and length changes depending on the situation but the basic structure remains the same.
Today we're going to talk about the basic SOAP note structure and what a medical SOAP note would look like. There are four main parts to the SOAP note and each part has a couple key sub parts. Luckily the name SOAP is an acronym and reminds you what those parts are. S stands for subjective, O for objective, A is assessment or what you think is going on with the patient, and P is the plan of action. The subjective section of your SOAP note should contain information gathered by talking to the patient, the family members and the medical record review. Depending upon the nature of the encounter, it may include any or all of the following sections I've listed here.
In a comprehensive or really expanded SOAP note, most often called a History and Physical, you will review and document all of these sections. For more focuses notes like postsurgical progress notes or sick visits, you'll include only those sections that are important to the encounter. Remember the O stands for objective. This is where you record your physical findings. This section should not contain anything the patient has told you. Note only your objective observations. Also you may use information such as age and laboratory and diagnostic test results but remember it's just the facts. This section should contain notes about the patient's general appearance, their vital signs and findings from the systems examination like eyes, ears, nose and throat, cardiac and respiratory. The amount that you review and document really depends on the reason you're seeing the patient.
Moving on, the assessment portion of the SOAP note is really based on the information you gathered in the subjective and objective sections. It combines all the information you have so far and allows you to be able to decide what you think is going on with the patient. Depending on who's writing the note, the information in this section could be left as a general statement of what might be going on or it could include more detailed information like the differential diagnosis and a list of billable medical diagnoses that you're seeing the patient for today.
Finally the plan is where the writer gets to decide what to do. This can include ordering or requesting consultations. If it's a medical clinician writing the note, then it may include prescriptions, treatments and diagnostics like chest x-rays. It could also include patient education and anticipatory guidance and then directions on when the patient should follow up are also really important. Okay, so now you know the basics of the SOAP note. Let's go through an example and put this all together.
Today we're going to see Mr. Fred Kealoha. He is a 62-year-old male who brings himself to the clinic complaining of a sore throat. Let's walk through and actually write the SOAP note. The first part is a summary of what the patient tells you. When you document, you want to be concise and only summarize the important information like the timing and severity of the symptoms and any other symptoms that are or aren't present. I'm going to document that Mr. Kealoha is in today with a sore throat. That's going to be the chief complaint.
The history of present illness or the story of his chief complaint is going to start with: He is a 62-year-old male with a history of hypertension and he presents today with 6/10 constant pain, worse at night. Started two days prior to the visit. He has associated symptoms of fever, T max of 102. He denies headache, rhinitis, congestion, sinus or facial pain, nausea, emesis, cough or shortness of breath. I know from reviewing his chart and confirming with him that he has already had his flu shot for the year and he is still on lisinopril 10 mg for hypertension. He has allergies to sulfa drugs. He doesn't smoke, only drinks socially and denies illicit drug use. You notice that I didn't put anything in about his social or family history because that's not really pertinent to his case.
Let's go on to document the examination. The vital signs include a heart rate of 77, respiratory rate of 16, blood pressure of 158/92 and temperature of 100.3 Fahrenheit. For the general survey I commented that Mr. Kealoah was an elderly male, alert and in no apparent distress. His eyes, ears and nose examination were all normal. His throat, however, wasn't. The back of his throat called the posterior oropharynx, was red and inflamed. His tonsils were hypertrophied and had a moderate amount of white exudate which is the medical way of saying he had a bunch of white junk on big tonsils. When I examined the lymph nodes in his neck, I noticed tender anterior cervical nodes on both sides. His heart and lung examination were normal.
Based on all that information, I can make my assessment or my diagnosis. Starting with the global assessment, I summarized that the patient is a 62-year-old male with a history of hypertension who is in today with sore throat. The clinical picture suggests streptococcus pharyngitis due to 4/5 points on the modified Centor criteria. Differential diagnosis includes viral pharyngitis or retropharyngeal abscess. I'm going to diagnose him with streptococcus pharyngitis and also uncontrolled hypertension.
Next you get to develop the plan. For his throat infection I'm going to prescribe penicillin VK 500 mg three times a day for five days. I'm going to have him continue supportive care with salt water gargling, Tylenol and ibuprofen for pain. There aren't any labs or consultations needed. I'm going to have him follow up in three days if no improvement, sooner if the symptoms worsen. For his hypertension I'm going to increase his lisinopril from 10 mg up to 20 mg because he's not yet to goal.
So that's the basic structure of the SOAP note. Subjective or what the patient tells you. Objective, what you see. Assessment, what you think is going on based on the subjective and objective information and the plan, what you're going to do about it all. I go into this in more detail for the nurse practitioner students. If you're interested in learning more, you can check out that lecture later.