PEARLS FOR SOAP NOTES – Online Nursing Essays
Hello Class,
I am going to give you pointers for SOAP notes and the preferred way of doing them. My comments are in RED. You may find them on your WEEK 4 assignments once they are graded. These suggestion are to HELP you become more efficient with your SOAP notes for this class and in the future.
Present your assignments NEAT and PRECISE. This is a Masters LEVEL Course.
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Comprehensive SOAP Note Template
SUBJECTIVE DATA: NOTHING goes here this is a HEADING.
Chief Complaint (CC): The CC or presenting problem is reported by the patient. This can be a symptom, condition, previous diagnosis or another short statement that describes why the patient is presenting today. The CC is similar to the title of a paper, allowing the reader to get a sense of what the rest of the document will entail. Examples: chest pain, decreased appetite, shortness of breath.
History of Present Illness (HPI): The HPI begins with a simple one line opening statement including the patient’s age, sex and reason for the visit.
- Example: 47-year old female presenting with abdominal pain.
This is the section where the patient can elaborate on their chief complaint. An acronym often used to organize the HPI is termed “LOCATES”:
- Location: Where is the CC located?
- Onset: When did the CC begin?
- Characterization: How does the patient describe the CC?
- Associated signs and symptoms
- Timing: Is the CC worse (or better) at a certain time of the day?
- Exacerbating/ relieving factors : What makes the CC better? Worse?
- Severity: Using a scale of 1 to 10, 1 being the least, 10 being the worst, how does the patient rate the CC?
It is important for clinicians to focus on the quality and clarity of their patient’s notes, rather than include excessive detail.
DO NOT leave this information as LOCATES. Information gathered from LOCATES should be in PARAGRAPH form.
Medications: LIST the medications with each medication on a separate line. Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products
Allergies: LIST each Allergan on a separate line with the reaction to the Allergan. Include medication, food, and environmental allergies separately.
Past Medical History (PMH): This should be a LIST of medical diagnoses/medical problems with each one on a separate line. Pertinent current or past medical conditions.
Past Surgical History (PSH): This should be a LIST with each Surgery and a DATE if known. It’s ok to say No History Reported.
Sexual/Reproductive History: Document Menarche, LMP, Birth Control use and any pregnancies. Sexual preference.
Personal/Social History: Include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system. An acronym that may be used here is HEADSS which stands for Home and Environment; Education, Employment, Eating; Activities; Drugs; Sexuality; and Suicide/Depression.
Health Maintenance: Include things like regular checkups, emphasizing health promotion and disease prevention. Pap history is an example.
Immunization History: Include immunization status (note date of last tetanus for all adults) For children, include the immunization history.
Significant Family History: This works better as a LIST with each family history on a separate line with their medical conditions and medical diagnoses.
Need to do this as a LIST and not combine medical history. There should be 3 generations of family member and their medical history and medical conditions.
Mother
Father
Sister
Brother
Children
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Review of Systems: This is what the patient tells you, they can deny, admit to, endorses, etc.
From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information you include in this section is based on what the patient tells you. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.
DO NOT leave the above highlighted information on your SOAP note. The directions are for YOU!
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
HEENT: Must Review each part, Head, Eyes, Ears, Nose and Throat.
Head: Dizziness, fainting, lightheadedness, headaches, pain, head injury/sequelae, stroke
Eyes: Use of corrective glasses/contact lenses, current vision, vision changes, last vision examination/results, injuries, excessive
tearing, redness, discharge, infections, double/blurred vision, spots, specks, flashing lights, glaucoma, cataracts
Ears: Hearing acuity/impairment, hearing aid use/effectiveness, tinnitus, vertigo, discharge, pain, earaches, infections, diseases
Nose/Sinuses: Frequent colds, nosebleeds, stuffiness, discharge, itching, obstruction, injury, seasonal problems/allergies, sinus infections, postnasal drip, sense of smell.
Throat: Teeth/gums condition, sores/ulcers/bleeding gums, last dental exam/results, frequent sore throat, burning/soreness of tongue, dry mouth, voice changes, hoarseness.
Neck: Lumps, “Swollen glands”, Goiter or growth on neck, Pain/tenderness, Stiffness, Thyroid disorder
Respiratory: Cough, Sputum production, including quantity, appearance, color. Coughing up blood , Shortness of breath, wheezing, history of asthma, tuberculosis, pleurisy, bronchitis, emphysema, or pneumonia. Last TB test and results, Last chest x-ray and results. Current and history of smoking, tobacco use and plan to quit.
Breast: Lumps, thickening, pain or tenderness, skin changes, Nipple discharge and color. Self-examination. Last provider examination, Last mammogram or ultrasound and results. Breastfeeding history.
Cardiovascular: Chest pain, Heart disease, High blood pressure, Palpitations, irregular heart rate, Cyanosis, Shortness of breath with exertion/lying flat/sleeping. History of rheumatic fever or heart murmur. Last electrocardiogram or other heart test.
Peripheral Vascular: Pain or cramps in legs, calves, thighs, hips when walking. Varicose veins, Edema, Thrombophlebits/phlebitis, Color or temperature changes of extremities. Hair loss on legs, Ulcers.
Gastrointestinal: Appetite, Swallowing difficulty. Excessive hunger or thirst, Excessive belching or passing gas. Heartburn, reflux, nausea, vomiting, cough. Distention, constipation, diarrhea, abdominal pain. Changes in stool color, amount, consistency, frequency. Rectal bleeding, tarry stools, hemorrhoids. Laxative or antacid use. Rectal pain, pain with defecation, Jaundice, liver disease, hepatitis. Gall bladder disease. History of abdominal x-rays or scans and results.
Genitourinary: Frequency, urgency, incontinence, retention. Difficulty beginning or maintaining urine stream. Change in force of stream. Polyuria, nocturia, Burning or painful urination, Hematuria, infections, stones. Kidney or flank pain, you know Ms. showed a medicine ruptured aneurysm bed-wetting, dribbling, Change in urine color or odor.
Musculoskeletal: Weakness, pain, stiffness, redness, swelling, cramps. Neck or back problems. Limitation of movement, Arthritis. Gout or Deformities.
Neurological: Fainting, dizziness, vertigo, blackouts. Seizures, paralysis, headaches, stroke, Numbness, tingling, burning. Tremors or other involuntary movements. Loss of memory, Nervousness, depression, anxiety, suicide attempt, hallucinations.
Hematologic/Immune: Blood type. History of anemia, Easy bruising/bleeding. History of transfusions/reactions, Allergies. Unexplained infections, Node enlargement.
Endocrine: Weight/height changes unexplained. Thyroid disorder, Intolerance to heat or cold, Excessive sweating, thirst, hunger, urination. Change in glove size/shoe size/facial structure.
Psychiatric: Changes in attention, mood, speech, gait, behavior, judgment, insight, or orientation.
Skin/hair/nails: Include rashes, lumps, sores, itching, dryness, changes, etc… Excessive changes in skin/hair.
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OBJECTIVE DATA: NOTHING goes here this is a HEADING.
From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see.
DO NOT leave the above highlighted information on your SOAP note. The directions are for YOU!
Physical Exam: Nothing goes here. This is a Subheading
Vital signs: Always need a set of Vital Signs
General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things.
HEENT: Must examine all the parts.
Neck: Inspect and palpate. Look for tenderness. Percuss and auscultate. Document your findings.
Chest/Lungs: Always include the heart in your PE. Inspect and palpate anterior chest for breathing pattern, fremitus, muscle and bone structure symmetry, or tenderness. Percuss and auscultate anterior . Document your findings.
Heart/Peripheral Vascular: Always include the heart in your PE. Look, listen and feel. Inspect, Palpate and Auscultate. Document your findings.
Abdomen: Examine all parts of the abdomen. Inspect and palpate. Look for tenderness. Percuss and auscultate. Document your findings.
Genital/Rectal: May defer this area.
Musculoskeletal: Inspect and palpate. Look for tenderness. Test ROM. Document your findings.
Neurological: Some assessment of the patient’s mental status occurred from first meeting the patient, conducting the interview to gather history data.
Skin: Include rashes, lumps, sores, itching, dryness, changes, etc
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses.)
DO NOT leave the above highlighted information on your SOAP note. The directions are for YOU!
ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled.
DO NOT leave the above highlighted information on your SOAP note. The directions are for YOU!
PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.
