SOAP Notes Chapter 5 1 Objectives Define the

SOAP Notes Chapter 5 1

Objectives § Define the subjective, objective, assessment, and plan components of a SOAP note § Organize pertinent positive and negative aspects of the history in the Subjective portion of the note § Organize pertinent positive and negative findings of the physical examination in the Objective portion of the note § Generate Assessments by analyzing information from the Subjective and Objective portions of the note § Document Assessments using terminology consistent with ICD-9 codes § Identify components of patient management that should be documented in the Plan section of a note 2

SOAP § Stands for Subjective, Objective, Assessment, and Plan § SOAP notes are a variation of the comprehensive history and physical examination § Represents one format to document a patient encounter systematically and logically § May be tailored to use in different practice settings § All sections of a SOAP note are inter-related 3

Subjective § What the “subject” tells you; the history § Typically includes Chief complaint History of present illness Pertinent past medical history Pertinent family history Pertinent psychosocial history Any specialized history related to the chief complaint (e. g. , obstetrical and gynecological history for a female patient who presents with irregular menses) § Pertinent review of systems § § § § Determining “pertinent” incorporates a lot of medical knowledge and experience 4

Subjective § Subjective information may be obtained from someone other than the patient § Spouse or family member § Caregiver § Other members of the health-care team § If someone other than the patient provides the history, document who provided the history and his or her relationship to the patient 5

Subjective § Use quotation marks to identify specific quotes from the patient, especially for CC, HPI § Acceptable to “translate” lay term into a medical term for history § Patient states “I had my gallbladder out” should be documented as “cholecystectomy” § An important function of the history is to establish patterns, through the presence or absence of certain findings, that pertain to specific conditions 6

Positives and Negatives § Pertinent positives are findings from the history, that by their presence, support or suggest one diagnosis (or pattern) more than another § Pertinent negative findings, or lack of findings, are those that, by their absence, support or suggest one diagnosis (or pattern) more than another § Documentation of pertinent positives and negatives should be detailed enough to narrow the differential diagnoses and eventually lead to the most likely diagnosis 7

Objective § Findings that you or others can observe § Typically include § § Vital signs A general assessment of the patient Physical examination findings Results from laboratory or diagnostic studies 8

General Assessment § May not always be included in a note in an officebased encounter, especially if patient is already known to the provider § May be helpful in certain settings or with certain more serious or urgent chief complaints, or when patient is unknown to provider § General assessment is documented to help identify a patient and paint a picture of the patient’s overall presentation and status 9

Objective § Should flow logically from the subjective and should reflect your differential diagnoses § Differential diagnoses of a complaint will help determine which systems are examined § Physical examination is typically documented in a head-to-toe format, regardless of the order in which the exam is conducted § Objective includes more than just the physical examination 10

Objective § Includes results of laboratory or other diagnostic tests that are known § If tests will be ordered, document in Plan portion of the SOAP notes § State name of test, then provide the values § Including values provides more specific information than documenting descriptors, such as WNL, normal, or stable § Allows other readers to make their own interpretation of the values 11

Objective § Document who is interpreting the study § “My interpretation of the EKG is that ischemic changes are present in the anterolateral leads” § “Dr. Jones’ interpretation of the chest x-ray is that bilateral pleural effusions are present” 12

Assessment § Usually the same as diagnosis or impression, although may be a symptom if a diagnosis has not yet been established § Careful analysis and interpretation of the subjective and objective data should lead to a logical assessment § As subjective and objective data are assimilated, the list of differential diagnoses, or assessments, becomes more refined 13

Assessment § Although not always necessary, results of laboratory and other diagnostic studies may help confirm a suspected diagnosis § A definitive (or final) diagnosis is based on diagnostic evidence § When a definitive diagnosis has not been reached, the assessment should reflect the presenting symptom or complaint and then list some of the most likely differential diagnoses with the term “rule out” 14

Assessment § The first assessment listed should usually correlate with the presenting complaint § As you uncover other diagnoses, list them in order of importance or impact on the chief complaint § Co-morbidities that may influence the patient’s medical course should also be listed 15

Plan § Each diagnosis or condition documented in the assessment should be addressed in the Plan § Includes documentation of diagnostic studies, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits 16

Plan § Documentation in the subjective, objective, and assessment sections of the note should establish the rationale for any testing ordered by the health-care provider as part of the Plan § If a consultation is being obtained, document if it is to establish a definitive diagnosis, to evaluate a known condition, or for treatment of an acute or chronic condition 17

Plan § In more than two-thirds of ambulatory care office visits, the patient leaves with medications or a prescription § Specific details of prescribed medication must be documented, such as name, dose, route of administration, frequency of administration, and duration § The same details should be documented for OTC medications that have been recommended 18

Plan § When prescribing or recommending a medication for use as needed (PRN) documentation should indicate what condition or symptom the medication treats § Documentation should also address any change in current medications, such as adjusting the dosage or frequency, or discontinuing a medication 19

Plan § A wide variety of non-pharmacologic treatment modalities may be included in the patient’s overall management plan § Behavioral and lifestyle changes, such as smoking cessation, weight loss, exercise, relaxation techniques, and dietary adjustments are often recommended § Patient education is an important adjunct to therapeutic recommendations 20

Plan § Patient satisfaction surveys report that patient education is considered an important indicator of the quality of care received § Educating patients about their condition or disease enables them to take control of their health § Patients should be encouraged to be active participants in their own health care, which often improves compliance with treatment 21

Plan § Printed handouts are valuable tools to reinforce instructions given verbally to patients § Documenting which handouts and materials you gave the patient may prompt you to inquire about the patient’s understanding of the material at a subsequent visit § You should determine the patient’s ability to read and understand the material prior to distributing written materials 22

Plan § Document follow-up instructions at every patient visit, regardless of the reason for the visit § Specific information that should be documented includes when the patient should return for follow -up, signs or symptoms that could indicate worsening of the patient’s condition, and what to do if those signs or symptoms develop § Time frame for routine follow-up is usually determined by how soon you would expect a patient to exhibit a response to the treatment initiated 23

Points to Ponder § Discuss how the subjective portion of a SOAP note might differ for a patient with a complaint of cough at age 10 compared to a patient who is 50. § Do you think the objective portion would be different? If so, how? § What elements of the PMH, FM, and SH would be “pertinent” for these different-aged patients? 24

Points to Ponder § A 32 -year-old woman presents with abdominal pain. What parts of the history would be pertinent for this patient? § What specialized history would be indicated? § How would the pertinent elements differ if the patient was an 82 -year old man? § Discuss the importance of documenting the general assessment as objective data. 25

Credits Publisher: Margaret Biblis Senior Acquisitions Editor: Andy Mc. Phee Developmental Editors: Nancy Hoffmann, Stephanie Rukowicz Production Manager: Sharon Lee Manager of Electronic Product Development: Kirk Pedrick Electronic Publishing: Sandra Glennie The publisher is not responsible for errors of omission or for consequences from application of information in this presentation, and makes no warranty, expressed or implied, in regard to its content. Any practice described in this presentation should be applied by the reader in accordance with professional standards of care used with regard to the unique circumstances that may apply in each situation.