Exam V: SOAP Notes

“Acronym for an organized structure for keeping progress notes in the chart”

Subjective
Objective
Assessment
Plan

Starts with Date and Time in the left upper corner
Required by law on every medical document
Every Note must contain the patient’s name somewhere on the sheet along with medical record number
Electronic record
Printed sticker
Hand written

Chronology

Onset

Duration

Intensity

Exacerbation

Remitting

Symptoms associated

Have you had this before

When did you have it

How many times

What did you do for it

Did you see a physician

What did they do

Did that work well

Onset
When did this start
What were you doing

Duration
How long does it last
Has it changed

Intensity
How bad is it
1-10 scale

Exacerbation
What makes it worse

Remission
What makes it better
IF a drug made it better: what drug, how much, how often

Surgical history

Medical history

Allergies

Social history (see next slide)

Hospitalizations

Family history

Medications

FED TACOS

Food (diet)

Exercise

Drugs

Tobacco

Alcohol

Caffeine

Occupation

Sexual history

MOTHRR

Medications

OMM

Tests

Holistic/Humanistic

Referrals

Return

CODIERS SMASH FM FED TACOS
What the patient tells you
You are not responsible for making certain it is absolutely correct
You ARE required to record it as accurately as possible

Chief Complaint= simple, best if in the patient’s own words
History of Present Illness
CODIERS – Paragraph format; chronology all together

Symptoms Associated
Pertinent Positives- “patient states”
Pertinent Negatives- “patient denies”

SMASH FM – Bulleted format

Vital Signs, Physical exam, test results

Facts that you have determined

YOU ARE responsible for the veracity

Always record this accurately

NEVER record anything you did not actually check

Outline format to make it easy to read

Physical Examination- bulleted with headings with vitals and general assessment

Then work Head to Toe

HEENT – blah blah blah

Respiratory – yada yada yada

Cardiac – etc. etc. etc.

Abdominal

Musculoskeletal

Neurologic

Genitalia

Test results

Differential Diagnosis
Primary diagnoses first
You must commit to some kind of primary diagnosis even if it comes out “I think you have”
First choice cannot be “Rule out” or “Doubt”
Second and third may be “Rule out”
Label unlikely diagnosis as “Doubt”
Must have 3 diagnoses related to the CC to break even, a 4th will get you one point added (COMLEX)

Secondary diagnoses next
These do not relate to the CC
Any other diagnosis you intend to address
Hypertension, Diabetes, Bee sting allergy

MOTHRR
Medications – OTC/prescriptions
OMM – not all cases get OMM; may put “will perform OMM next visit”
Tests – Labs/Imaging
Holistic/Humanistic: rest, heat, elevation, not eating before bed; offering to contact family members
Referrals – may also be left out
Return to office – follow-up, call instructions
ALWAYS have a return plan
Hospital admission counts as “Return”

Your signature and date directly underneath last line so no one can accidentally write in your section

Date/Time:

Patient ID: one sentence describing significant PMhx and procedure

79 y/o CF with h/o htn, dm for lap chole

Brief hx and physical (See complete pre-op H&P)

Meds:

Allergies:

Labs: including results of pregnancy test

CXR:

EKG:

Operative consent: signed

Legible Name and Signature

Date/Time:

Surgeon:

Assistant:

Pre-op dx

Post-op dx

Procedure

Anesthesia: type i.e. general via ETT, via mask, spinal, regional, local

Fluids

EBL:

U.O.

Drains/tubes

Post op condition

Legible Name and Signature

Operative Note: dictated by surgeon directly afterward; more in depth than the above

Date of Admission

Date of Discharge

Admitting diagnosis

Final diagnoses

Consultations

Operations/Procedures

Brief History and Physical

Pertinent Labs

Hospital Course

Disposition

Discharge medications

Discharge instructions

From left to right:

Na/K
Cl/HCO3
BUN/Creatinine
Glucose