SOAP Notes

1. SOAP Notes Health Care Documentation Heather Peterson October 10, 2005

2. Documentation • Cases for oral health care • Interview and Counsel patients • Write a SOAP note about the interaction • Can use SOAP checklist on Blackboard • Present to class

3. Header • Patient name • Age • Chief complaint • Allergies • Can see these as a header at the beginning of the SOAP note or within the S and O parts.

4. Subjective • Written in full sentences, paragraph form. • Identify patient and give brief description of encounter • Mrs. Johnson, a 47 yo woman, presents to the pharmacy with a question about canker sores. • State patient’s complaints • One sentence in patient’s words • “I keep getting these painful white dots in my mouth. How do I treat them?” • 8 attributes • Histories if pertinent: PMH, FH, SH

5. Subjective example Sylvia York DOB: 1/27/76 CC: headache NKDA 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 her head, accompanied by some nausea, photophobia and phonophobia. 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 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 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. 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 other Rx drugs, OTC drugs or supplements. She does not smoke or drink alcohol. She drinks 2-3 caffeine drinks a week.

6. Objective • Written in list format typically. • Allergies • Medications (Rx, OTC, supplements, herbal) • Physical exam: vital signs, any physical assessment (describe patients appearance) • Patient has a flat, oval ulcer with erythematous tissue around it on the right inner cheek. • Pertinent labs, test results (not usually in community setting)

7. Objective example • O – Sylvia appears healthy, but somewhat stressed and uncomfortable • Medical dx: Allergies: Migraines NKDA • Medications: Ortho Tri-Cyclen Lo4/30/02 to 5/25/05 Ortho Tri-Cyclen samples since 05/25/05 • B.P: 116/74 mm Hg

8. Assessment • Written in full sentences, paragraph form. • All issues in S & O addressed in A • Supporting data for assessment should be found in S & O • Organize, prioritize by disease state, complaint, drug related problem • State the problem, disease, etc – justify decision by discussing other options and how you reached conclusion. • Goals for treatment • Justify recommendations – discuss other options and why option chosen • Safety, tolerability, efficacy/evidence, price, simplicity

9. Assessment Example 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 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 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 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 normal functioning so the patient can study, and prevent relapse. It is recommended she speak with her PCP about her increase in migraines since 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 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 antihistamine, diphenhydramine which may make her drowsy. Other OTC 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. Successful use of acetaminophen of the past makes it a reasonable initial choice for self-treatment.

10. Plan • Written in brief sentences, concise and complete. • Provides actions to be taken based on A, includes treatment, monitoring, education. • Medication recommendation: drug, dose, route, frequency, duration. • Monitoring: efficacy and toxicity parameters, timeframe for effect, precautions, SE. • Follow-up

11. Plan example P –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 hours. The medication should take effect within 1 hour. She is not to drink alcohol while taking the medication or take any other acetaminophen containing products during this time. It is also 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 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 months. She will call the pharmacy to report on the efficacy of the chosen therapy..

12. Closing • Sign name and title • Date

13. All sections • Written in ink (black or blue) • Abbreviations and symbols can be used • Mistakes are crossed out with a single strike and initialed. • Legal document! • Never write offensive or accusatory statements • Grammer and spellling

14. Clinic SOAP example Patient Name: Robert Dreg DOB: 09/17/1967 Record No. D-679dk978 Date: 12/4/99 S—Pain in left hip x 3 months; worse when walking or doing exercise. NKDA. O—Wt. 195 lb, Ht. 5'5'', normal ROM both hips, no swelling or redness. A—Possible osteoarthritis; R/O rheumatoid arthritis P—bloodwork—sed rate, rheumatoid factor, x ray L hip PA and lateral; ibuprofen 600 mg t.i.d po; recheck 2 months. ------------------------------------------------------- Bob Ridman, CCMA Brenda D. Fleiss, MD