Writing in a SOAP note format-Subjective, Objective, Assessment, Plan-allows healthcare practitioners to conduct clear and concise documentation of patient information. Try to view SOAP notes as learning opportunities, and with enough effort and time, you’ll become proficient in drafting these vital medical communications.Įxplore solutions for practicing clinicians, residents, students, and faculty from Lippincott Medicine and deliver better patient outcomes.SOAP Note Assessment Example | See Full Sample PDF Report If you’re taking care of an inpatient, be sure also to note their deep vein thrombosis prophylaxis, code status and disposition.Īs with any skill, practice makes perfect. For example, if you’re in the midst of treating a bacterial infection, indicate that you plan to continue antibiotics.ģ. Propose a plan to manage each problem you’ve identified. Your problem list should be ordered by acuity.Ģ. Create a list of all of the patient’s medical problems. Aim to include at least two or three possible diagnoses. If your patient is experiencing any new symptoms, be sure to include a differential diagnosis as well. She is now clinically stable and has transitioned from intravenous to oral antibiotics.” If the patient has multiple major diagnoses, these should all be mentioned in your summary statement.Ģ. K is an 85-year-old woman with a past medical history of multiple urinary tract infections who presented to the emergency room with dysuria, fatigue and a fever secondary to a new urinary tract infection. Craft a one- to two-sentence summary that includes the patient’s age, relevant medical history, major diagnosis and clinical stability. Any other relevant diagnostic information, including electrocardiograms.Īfter you’ve completed the subjective and objective sections of your note, report your assessment.ġ.Imaging, including X-rays, computed tomography scans and ultrasounds.Laboratory tests, including basic metabolic panels, complete blood counts and liver function tests. Report the results of any other diagnostics that have been performed, such as: Additionally, include the results of any other relevant exams you’ve performed.ģ. Begin with a general impression of the patient, followed by the results of your head, ears, eyes, nose and throat respiratory cardiac abdominal extremity and neurological exams. Be sure to record the patient’s temperature, heart rate, blood pressure, respiratory rate and oxygen saturation.Ģ. The objective section of your SOAP note should, unsurprisingly, comprise objective information you collect from the patient encounter.ġ. A current list of the patient’s medications, including the doses and frequency of administration. Pertinent medical history, including the patient’s:Ĥ.
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