The SOAP Note and
Presentation
Melanie G. Hagen, MD
Rebecca R. Pauly, MD
University of Florida
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The SOAP Note and
Presentation
Melanie G. Hagen, MDRebecca R. Pauly, MD
University of Florida
Use the SOAP Format for allOral Presentations and Notes z
Sometimes the term “SOAP” note is only applied toshort notes but the format is used throughoutmedical practice for communication. z Subjective z Objective z Assessment z Plan
SOAP Notes z
Objective z
This section includes observations andmeasurements that you have made during thephysical examination. z Includes the vital signs. z Includes a general description of the patient. z Results of diagnostic testing also go here. z Laboratory results z Imaging z Pathology reports
SOAP Notes z
Assessment z
What do you feel is the patient’s differentialdiagnosis and why? z This is organized by problem or organ system.
The Complete PatientEvaluation z
Used for new patients in hospital or clinic z History and Physical (H & P) z Complete story of their illness and medical history z Cc and HPI z Past Medical History z Active Medical Problems z Surgical and Trauma History z Childhood Illnesses z Medications and Allergies z Social History z Family History z Review of Systems z Physical Examination z Labs and other diagnostic studies z Assessment z Plan
The Progress Note z
Uses: z
Daily evaluation of a hospitalized patient z Return visit in outpatient clinic z
Focused history
z
Focused physical examination
The Complete History andPhysical z
Objective z
Vital signs z Your physical exam findings z Any diagnostic test results z Lab work z Imaging
The Complete History andPhysical z
Assessment z
Problem list with differential diagnosis for eachproblem z
Plan z
Action planned for each problem z
The assessment and plan may be combinedas the A & P
Sample SOAP Note z
About two weeks ago her right cheek started to hurt.The pain is 5/10 in severity and worse with leaningher head down, smiling and chewing. The over thecounter medicine is no longer helping. z She has not taken her temperature but felt she mayhave had a fever. She no longer has a runny nose,it just feels congested. She has no sore throat, noheadache, no ear pain and no cough. Symptomsare not worse at any time of day or in any particularlocation. No one at work or at home has been sick.
Sample SOAP note z
Objective: z Temperature 38 F z B/P 120/68, HR 76, RR 16 z Weight 129, BMI 26 z General: Fatigued appearing young woman z HEENT: Face: Right maxillary tenderness. No sinustransillumination on the right side. No conjunctivalinjection. Oropharynx: pink mucus membranes withouttonsillar exudates. Nasopharynx: thick green mucous anderythematous turbinates. Ears: tympanic membranespearly grey with a sharp light reflex.
Sample SOAP Note z
Assessment z Acute Sinusitis z Allergic Rhinitis z Plan z Treat with amoxicillin 500 mg three times a day and adecongestant as needed for one week. Follow up ifsymptoms have not improved. z Fluticasone nose spray for allergy symptoms whenneeded.
The Presentation z
Used for communication between clinicians.
z
Should be a well-organized vignette thatcaptures the patient and his or her clinicalproblem. z
Your goal is to help your listeners to visualize thepatient and understand the problem
The Presentation z
In clinic: z Immediately after yousee a patient z In the hospital: z On rounds
The Presentation z
Begin with an opening statement z “Chief complaint: Shortness of breath. Mr. Smith is an 84year retired dentist with a history of hypertension who hasnew shortness of breath and lower extremity edema.” z “Mrs. Brooks is a 49 year old teacher with a history offibrocystic breast disease who is anxious about a newtender breast lump.”