SOAP NotesSOAP Notes

Health Care DocumentationHealth Care Documentation

Heather PetersonHeather PetersonOctober 10, 2005October 10, 2005

DocumentationDocumentation

Cases for oral health careCases for oral health care Interview and Counsel patientsInterview and Counsel patients Write a SOAP note about the interactionWrite a SOAP note about the interaction

Can use SOAP checklist on BlackboardCan use SOAP checklist on Blackboard

Present to classPresent to class

HeaderHeader

Patient namePatient name AgeAge Chief complaintChief complaint AllergiesAllergies

Can see these as a header at the Can see these as a header at the beginning of the SOAP note or within the beginning of the SOAP note or within the S and O parts.S and O parts.

SubjectiveSubjective

Written in full sentences, paragraph form.Written in full sentences, paragraph form. Identify patient and give brief description of Identify patient and give brief description of

encounterencounter Mrs. Johnson, a 47 yo woman, presents to the Mrs. Johnson, a 47 yo woman, presents to the

pharmacy with a question about canker sores.pharmacy with a question about canker sores. State patient’s complaints State patient’s complaints

One sentence in patient’s wordsOne sentence in patient’s words ““I keep getting these painful white dots in my mouth. How I keep getting these painful white dots in my mouth. How

do I treat them?”do I treat them?” 8 attributes8 attributes

Histories if pertinent: PMH, FH, SHHistories if pertinent: PMH, FH, SH

Subjective exampleSubjective example

Sylvia YorkSylvia York DOB: 1/27/76DOB: 1/27/76CC: headacheCC: headache NKDANKDAS-Sylvia York, a 27 year old female presents to the pharmacy asking about S-Sylvia York, a 27 year old female presents to the pharmacy asking about

treatments for a headache. She has throbbing pain on the right side of treatments for a headache. She has throbbing pain on the right side of her head, accompanied by some nausea, photophobia and phonophobia. her head, accompanied by some nausea, photophobia and phonophobia. She rates the pain 7 out of 10. She has been diagnosed with migraines 3 She rates the pain 7 out of 10. She has been diagnosed with migraines 3 years ago but didn’t start having them often until a few months ago. She years ago but didn’t start having them often until a few months ago. She has had 3 in the past 2 months. She usually takes 2 Tylenol PM and has had 3 in the past 2 months. She usually takes 2 Tylenol PM and sleeps through the pain in a dark, quiet room. The headaches typically sleeps through the pain in a dark, quiet room. The headaches typically last 4 to 6 hours. She cannot do that this time because she recently last 4 to 6 hours. She cannot do that this time because she recently started taking night classes and has to stay up tonight to study for a test. started taking night classes and has to stay up tonight to study for a test. Sylvia is currently taking Ortho Tri-Cyclen. She has been taking samples Sylvia is currently taking Ortho Tri-Cyclen. She has been taking samples for the past 4 months given to her by her doctor. She does not take any for the past 4 months given to her by her doctor. She does not take any other Rx drugs, OTC drugs or supplements. She does not smoke or drink other Rx drugs, OTC drugs or supplements. She does not smoke or drink alcohol. She drinks 2-3 caffeine drinks a week.alcohol. She drinks 2-3 caffeine drinks a week.

ObjectiveObjective

Written in list format typically.Written in list format typically. AllergiesAllergies Medications (Rx, OTC, supplements, herbal)Medications (Rx, OTC, supplements, herbal) Physical exam: vital signs, any physical Physical exam: vital signs, any physical

assessment (describe patients appearance)assessment (describe patients appearance) Patient has a flat, oval ulcer with erythematous Patient has a flat, oval ulcer with erythematous

tissue around it on the right inner cheek.tissue around it on the right inner cheek. Pertinent labs, test results (not usually in Pertinent labs, test results (not usually in

community setting)community setting)

Objective exampleObjective example

O – Sylvia appears healthy, but somewhat O – Sylvia appears healthy, but somewhat stressed and uncomfortablestressed and uncomfortable

Medical dx:Medical dx: Allergies:Allergies:MigrainesMigraines NKDANKDA

Medications: Medications: Ortho Tri-Cyclen Lo4/30/02 to 5/25/05Ortho Tri-Cyclen Lo4/30/02 to 5/25/05Ortho Tri-Cyclen samples since 05/25/05Ortho Tri-Cyclen samples since 05/25/05

B.P: 116/74 mm HgB.P: 116/74 mm Hg

AssessmentAssessment

Written in full sentences, paragraph form.Written in full sentences, paragraph form. All issues in S & O addressed in AAll issues in S & O addressed in A

Supporting data for assessment should be found in S & OSupporting data for assessment should be found in S & O Organize, prioritize by disease state, complaint, drug Organize, prioritize by disease state, complaint, drug

related problemrelated problem State the problem, disease, etc – justify decision by State the problem, disease, etc – justify decision by

discussing other options and how you reached discussing other options and how you reached conclusion.conclusion.

Goals for treatmentGoals for treatment Justify recommendations – discuss other options and Justify recommendations – discuss other options and

why option chosenwhy option chosen Safety, tolerability, efficacy/evidence, price, simplicitySafety, tolerability, efficacy/evidence, price, simplicity

Assessment ExampleAssessment Example

A –. Based on the location of the headache, the severity of the pain and the associated A –. Based on the location of the headache, the severity of the pain and the associated sx it is likely the patient has a migraine HA. Tension HA was ruled out because of sx it is likely the patient has a migraine HA. Tension HA was ruled out because of the location and severity of the HA. Rebound HA was ruled out because the the location and severity of the HA. Rebound HA was ruled out because the patient does not take analgesics regularly or drink caffeine regularly. An increase patient does not take analgesics regularly or drink caffeine regularly. An increase in the frequency of the headaches is associated with a change in oral in the frequency of the headaches is associated with a change in oral contraceptives. The newer formulation, Ortho Tri Cyclen, has a higher dose of contraceptives. The newer formulation, Ortho Tri Cyclen, has a higher dose of estradiol, which has been documented to increase the frequency and severity of estradiol, which has been documented to increase the frequency and severity of migraine headaches. The goals of treatment are to alleviate the acute pain, restore migraine headaches. The goals of treatment are to alleviate the acute pain, restore normal functioning so the patient can study, and prevent relapse. It is normal functioning so the patient can study, and prevent relapse. It is recommended she speak with her PCP about her increase in migraines since recommended she speak with her PCP about her increase in migraines since switching to Ortho Tri Cyclen. Extra Strength Tylenol (acetaminophen 500 mg) 2 switching to Ortho Tri Cyclen. Extra Strength Tylenol (acetaminophen 500 mg) 2 q4-6h prn pain is recommended to treat the current migraine. The patient has q4-6h prn pain is recommended to treat the current migraine. The patient has taken Tylenol PM (acetaminophen 500 mg and diphenhydramine 25 mg) in the taken Tylenol PM (acetaminophen 500 mg and diphenhydramine 25 mg) in the past and said it worked. Extra Strength Tylenol has the same analgesic without the past and said it worked. Extra Strength Tylenol has the same analgesic without the antihistamine, diphenhydramine which may make her drowsy. Other OTC antihistamine, diphenhydramine which may make her drowsy. Other OTC analgesics may be effective. Since she does not drink alcohol or have a history of analgesics may be effective. Since she does not drink alcohol or have a history of liver disease, she does not have any contraindications to acetaminophen. liver disease, she does not have any contraindications to acetaminophen. Successful use of acetaminophen of the past makes it a reasonable initial choice Successful use of acetaminophen of the past makes it a reasonable initial choice for self-treatment.for self-treatment.

PlanPlan

Written in brief sentences, concise and Written in brief sentences, concise and complete.complete.

Provides actions to be taken based on A, Provides actions to be taken based on A, includes treatment, monitoring, education.includes treatment, monitoring, education.

Medication recommendation: drug, dose, route, Medication recommendation: drug, dose, route, frequency, duration.frequency, duration.

Monitoring: efficacy and toxicity parameters, Monitoring: efficacy and toxicity parameters, timeframe for effect, precautions, SE.timeframe for effect, precautions, SE.

Follow-up Follow-up

Plan examplePlan example

P –P –Sylvia is to take 1-2 acetaminophen 500 mg tablet every 4-6 hours Sylvia is to take 1-2 acetaminophen 500 mg tablet every 4-6 hours as needed for migraine HA pain, NTE 4000 mg (8 tablets) in 24 as needed for migraine HA pain, NTE 4000 mg (8 tablets) in 24 hours. The medication should take effect within 1 hour. She is hours. The medication should take effect within 1 hour. She is not to drink alcohol while taking the medication or take any other not to drink alcohol while taking the medication or take any other acetaminophen containing products during this time. It is also acetaminophen containing products during this time. It is also recommended that she use an ice pack on the location of the pain recommended that she use an ice pack on the location of the pain and study in a quiet room. In the future she should keep a HA and study in a quiet room. In the future she should keep a HA diary to try to identify migraine triggers. She is to meet with her diary to try to identify migraine triggers. She is to meet with her PCP to discuss the increase incidents of migraines in the past few PCP to discuss the increase incidents of migraines in the past few months. She will call the pharmacy to report on the efficacy of the months. She will call the pharmacy to report on the efficacy of the chosen therapy..chosen therapy..

ClosingClosing

Sign name and titleSign name and title DateDate

All sectionsAll sections

Written in ink (black or blue)Written in ink (black or blue) Abbreviations and symbols can be usedAbbreviations and symbols can be used Mistakes are crossed out with a single Mistakes are crossed out with a single

strike and initialed.strike and initialed. Legal document!Legal document!

Never write offensive or accusatory Never write offensive or accusatory statementsstatements

Grammer and spelllingGrammer and spellling

Clinic SOAP exampleClinic SOAP example

Patient Name: Robert Dreg DOB: 09/17/1967Patient Name: Robert Dreg DOB: 09/17/1967Record No. D-679dk978Record No. D-679dk978Date: 12/4/99Date: 12/4/99SS—Pain in left hip x 3 months; worse when walking or doing —Pain in left hip x 3 months; worse when walking or doing

exercise. NKDA.exercise. NKDA.OO—Wt. 195 lb, Ht. 5'5'', normal ROM both hips, no swelling or —Wt. 195 lb, Ht. 5'5'', normal ROM both hips, no swelling or

redness.redness.AA—Possible osteoarthritis; R/O rheumatoid arthritis—Possible osteoarthritis; R/O rheumatoid arthritisPP—bloodwork—sed rate, rheumatoid factor, x ray L hip PA and —bloodwork—sed rate, rheumatoid factor, x ray L hip PA and

lateral; ibuprofen 600 mg t.i.d po; recheck 2 months.lateral; ibuprofen 600 mg t.i.d po; recheck 2 months.------------------------------------------------------- Bob Ridman, CCMA------------------------------------------------------- Bob Ridman, CCMABrenda D. Fleiss, MDBrenda D. Fleiss, MD