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How To Document A Patient Assessment SOAP PDF

This document discusses how to structure patient documentation using the SOAP format. The subjective section includes the patient's description of symptoms. The objective section contains measurable observations like vital signs and exam findings. The assessment analyzes the subjective and objective data to identify diagnoses. Finally, the plan outlines next steps for investigations, treatments, referrals, and follow ups. Proper documentation following this SOAP format provides a clear and complete record of each patient encounter.

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231 views

How To Document A Patient Assessment SOAP PDF

This document discusses how to structure patient documentation using the SOAP format. The subjective section includes the patient's description of symptoms. The objective section contains measurable observations like vital signs and exam findings. The assessment analyzes the subjective and objective data to identify diagnoses. Finally, the plan outlines next steps for investigations, treatments, referrals, and follow ups. Proper documentation following this SOAP format provides a clear and complete record of each patient encounter.

Uploaded by

aulia eka
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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How to Document a Patient Assessment (SOAP)

geekymedics.com/document-patient-assessment-soap/

Posted by Dr Lewis Potter | Documentation April 5, 2017

Documenting your assessments of patients in the notes is something all medical students need
to practice as you’ll be doing this on a daily basis once you start work as a doctor. This guide
discusses the SOAP (Subjective/Objective/Assessment/Plan) framework which should help you
structure your documentation in a clear and consistent manner. To learn more about
documenting in a patient’s notes check out our documentation section here.

The subjective section of your documentation should include how the patient is currently
feeling and how they’ve been since the last review in their own words.

So as part of your assessment you may ask:

“How are you today?”


“How have you been since the last time I saw you?”
“Have you currently got any troublesome symptoms?”
“How has the nausea been?” (or any other relevant symptom)

If the patient mentions multiple symptoms you should explore each of them, having the
patient describe them in their own words.

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You should document the patient’s responses accurately and use quotation marks if you
are directly quoting something the patient has said.

Objective
This section needs to include your objective observations, which are things you can
measure, see, hear, feel or smell.

Objective observations
Patient’s appearance (e.g. “Patient appears very pale and in discomfort“)

Basic observations (vital signs):

Blood pressure
Pulse rate
Respiratory rate
Oxygen saturations (including the amount of oxygen the patient is receiving if relevant)
Temperature (including any recent fevers)

Fluid balance (fluids going in and coming out):

Oral fluids
Nasogastric fluids/feed
Intravenous fluids
Urine output
Vomiting
Drain output / stoma output

Clinical examination findings:

“Widespread expiratory wheeze on auscultation of the chest”


“Abdomen soft and non-tender”
“Pulse irregular”
“No cranial nerve deficits”

Other investigation results:

Recent lab results (e.g. bloods/microbiology)


Imaging results (e.g. chest x-ray/CT abdomen)

Assessment

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The assessment section is where you write your thoughts on the salient issues and the
diagnosis (or differential diagnosis), which will be based on the information collected in
the previous two sections.

Summarise the salient points:

Productive cough (green sputum)


Increasing shortness of breath
Tachypnea (respiratory rate 22) and hypoxia (O2 saturations 87% on air)
Right basal crackles on auscultation
Bloods – Raised white cell count (15) / Raised CRP (80)
Chest x-ray – increased opacity in the right lower zone in keeping with consolidation

Document your impression of the diagnosis (or differential diagnosis):

Impression – Community acquired pneumonia

If the diagnosis is already known and the findings of your assessment remain in keeping
with that diagnosis, you can comment on whether the patient is clinically improving or
deteriorating:

On day 3 of treatment for community acquired pneumonia


Reduced shortness of breath and improved cough
Oxygen saturations 98% on air / Respiratory rate 15
Bloods – CRP decreasing (20) / White cell count decreasing (11)

Impression – Resolving community acquired pneumonia

Plan
The final section is the plan, which is where you document how you are going to address
or further investigate any issues raised during the review.

Things to consider including in your plan:

Further investigations – laboratory tests/imaging


Treatments – medications/IV fluids/oxygen/nutrition
Referrals to various specialties
Review date/time – “I will review at 4pm this afternoon”
Frequency of observations/monitoring of fluid balance
Planned discharge date if relevant

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