How to Write a SOAP Note
In this article, we go over how to write a SOAP note in full.
So what is a SOAP note?
A SOAP note is a note that is created for focused examinations on an individual, where the "focus" is on the patient's chief complaint.
SOAP notes are not History & Physicals; they are for focused examinations on a patient based on the patient's chief complaint.
When you write a SPAP note, you perform a focused examin and document it in
"SOAP" note format.
Components of a SOAP Note
The components of a SOAP note are easy to remember because SOAP is a mnemonic that uses all of the letters of SOAP.
"S" stands for subjective information.
"O" stands for objective information.
"A" stands for assessment (diagnosis).
"P" stands for plan (for the patient).
We go over all of these below.
Subjective "S"
The "S" in SOAP stands for subjective information.
Subjective information is anything that patient or family tells you.
The subjective information includes the chief complaint, the history of the present illness (HPI) which includes SLIDTA, and general history including past medical history (PMH), past surgical history (PSH), medications, and allergies.
The chief complain (CC) is limited to one complaint. The CC should be as brief as possible (as few words as possible). The duration should always be included.
An example of a CC: Sore throat for 3 days
The history of the present illness (HPI) should include SLIDTA. The HPI follows the chief complaint. The HPI should always start with, "This is a (age/race/sex)." It is written as a narrative statement. To obtain all this information, you ask the appropriate questions and records the patient's responses.You guide the patient to answer your questions.
For the HPI, you must include SLIDTA. SLIDTA is an acronynm. The "S" stands for severity; severity is rated on a pain scale, most commonly a scale from 0 to 10 where 0 is no pain and 10 is severe pain. The "L" stands for the location of the pain. "I" stands for influencing factors; this is what makes the pain worse or better. "D" stands for duration; this should match the duration in the chief complaint. "T" stands for type; this means the type of pain, including gnawing, sharp, mild, etc. "A" stands for associated symptoms; these are the other symptoms that a patient says s/he has besides the chief complaint.
Example of HPI: HPI: This is a 42-year-old caucasianwoman who complains of a sore throat has been present for the last 3 days. Reports that the pain gnawing and is localized to the tonsils and is a 9 out of 10 in severity. The pain is worse upon talking and swallowing. Using throat lozenges helps to soothe and ease the pain. Reports also a nausea and chills in the tonsil region. Denies any headaches.
Examining this HPI for SLIDTA, we see that the "S" is a 7 out of 10. The "L" is tonsils. The "I" is that the pain is worse upon talking and swallowing and that throat lozenges helps to make the pain better. The "D" stands for duration, which is 7 days. The "T" is a constant, sharp pain. The "A" is nausea and chills.
When writing the HPI, upon positive response, this should be written as, reports...Upon negative response, this should be written as, denies...
Omit "he" or "she" or "patient" or "patient says" or "patient reports"
The purpose of the HPI is to gather information in an orderly fashion to arrive at a diagnosis. 90% of the time the diagnosis is made by the end of the HPI, assuming the correct questions have been asking. Learning how to ask the right questions is key.
Once you have done the HPI, you should formulate differential diagnosies
in mind. Differential diagnoses are hypotheses as to what illness is the cause of the
patient's chief complaint. They are not written down at this point. When you consider
differential diagnoses, you should consider the patient's age and sex. Differential
diagnoses for abdominal pain in a 22-year-old male, for example, wouldn't
be the same as for a 62-year-old
female. Even though you are thinking of differential diagnoses at this stage, they
are not written down, as you havne't examined your patient yet. You are just having
the thoughts as to what the diagnosis could be. Your physical exam will be guided
by your differentials. Remember, this is a focused exam, so you aren't doing a complete
head-to-toe physical exam, but focusing on the problem as it relates to the differential
diagnosis (as that relates to the patient's chief complaint).
Objective "O"
After getting all of the subjective information from the patient, we now progress to the objective information.
At this point, we physically examine the patient.
One thing we should always get is the patient's vital signs, including the blood pressure, pulse, temperature, and respirations. You may also include the oxygen saturation, as determined by a pulse oximeter.
You also want the patient's height, weight, and body mass index (BMI).
After this, you want to generally survey the patient and write down a general survey. How does the patient appear? Well-nourished? Does the patient appear as the stated age? Is the patient's speech appropriate? Is the patient dressed appropriately for the current weather?
Example of a General Survey: This is a well-developed, well-nourished Hispanic female who appears as stated age. Speech clear, answers congruent with questions. Dressed appropriately for weather. No apparent distress noted.
With a physical examination, regardless of the complaint, you always want to examine the patient's heart and lungs.
You should ascultate the patient's lungs for its health condition.
A response may be the following below.
Lungs: Even and unlabored breathing, clear to auscultation.
You should also auscultate the patient's heart for its health condition. This is best done in the 5th intercostal space at the left midclavicular line. This is where you can hear the patient's apical pulse.
The normal sound to hear is lub-dub, without any S3 or S4 heart sounds.
A response may be the following below.
Heart: RRR, S1 S2, no murmurs, rubs, gallops, or click noted.
RRR stands for regular rate and rhythm.
The rest of the physical exam in a focused exam is based on the patient's chief complain, HPI, and your differentials.
For example, if the chief complaint is a sore throat, perform a throat examination, not a foot examination, for instance (unrelated to the chief complaint).
If the chief complaint is a cough, perform a full respiratory exam, but not a musculoskeletal exam.
So, again, the subjective information is what the patient tells you.
The objective information is what is there physically, as you examine the patient.
Assessment "A"
Based on the history you obtained in the HPI and your physical findings, you can then make the diagnosis.
The diagnosis is written in this section, the Assessment section.
When you write this diagnosis, include the ICD-10 code next to the diagnosis.
Below this new diagnosis, always include active medical conditions with
the ICD-10 code. For example, if the person has chronic, on-going diabetes and hypertension,
put these under this new diagnosis (with the ICD-10 code for these conditions).
Plan "P"
Lastly, we have the plan for our patient.
The plan covers these list of interventions below in the following order
Medications
Labs
Diagnostics
Referrals
Patient education
Follow-up
So if you are prescribing any medications for the patient, you will say what medications you are prescribing, along with evidence-based practice guidelines to why you are prescribing this medication(s).
If you will need any labs in order to confirm the differential diagnosis you suspect, then you will order labs and put these in labs. Again, you want to put evidence-based practice guidelines to why you are ordering these labs.
If you are ordered any diagnostic tests such as a CT scan, an MRI, these will put in diagnostics. Again, you would include evidence-based practice.
If the nurse practitioner isn't capable of making a confident diagnosis, a referral may be needed. For example, if a patient has an abnormal neurological exam, the nurse practitioner may refer to the patient to a neurologist for more extensive testing.
After this, we include patient education. What education should you give the patient based on this diagnosis?
Lastly, we include the follow-up information for the visit. Should the patient
come back in 7 days? Sooner? Later?