SOAP Note

LTG #

Allotted Lesson Time:

References: Nursing Procedures Manual
HM 3&2

Terminal Learning Objective: Given a simulated patient with a simulated complaint, the student will be able to obtain the needed information for proper treatment of the patient.

Enabling Learning Objective: Given a list of components of a SOAP note, select by shading the correct response.

1. The information charted for each component.
2. The proper way of obtaining the information for each component.

Problem oriented medical record approach (POMR)

The S.O.A.P.(E. R.) method is the only accepted method of medical record entries for the military.

1. S: (subjective) - What the patient tells you.
2. O: (objective) - Physical findings of the exam.
3. A: (assessment) - Your interpretation of the patients condition.
4. P: (plan) - Includes the following:
   1. Therapeutic treatment: includes use of meds, use of bandages, etc.
   2. Additional diagnostic procedures: any test which still might be needed.
5. E: (patient education) - special instructions, handouts, use of medications, side effects, etc.
6. R: (return to clinic) - when and under what circumstances to return.

Components of the SOAP note.

1. Medical History - Gives you an idea of the patients problem before you start physical exam.
   1. biographic data
   2. chief complaint
      1. This is the reason for the patients visit.
      2. Use direct quotes from patient.
      3. Avoid diagnostic terms.
   3. Observation: begins as soon as the patient walks through the door.
   4. Listening: listen carefully. This will help you get an accurate diagnosis of the problem.
   5. Open ended questions: help you to get more complete and accurate information.
   6. Provider obstacles: your attitude or predeterminations may prevent you from making an accurate judgment.
   7. Patient obstacles: the patient has many obstacles to overcome. Patients must have confidence in you.
2. History of present illness/injury (HPI)
   1. Duration: when the illness/injury started.
   2. Character: use the patients words to note character of pain.
   3. Location: have the patient explain, then have them point it out.
   4. Exacerbation or remission: what makes it better or worse and is it constant or does it vary in intensity.
   5. Positional pain: does the pain vary with the change of the patients position.
   6. Medications/allergies: note any medications whether over the counter or not. Do the medications relate to the problem? Take note of the patients allergies. Do not rely on the patients health record or SF 600.
   7. Pertinent facts: facts which lead you to your diagnosis. Usually consist of classical signs and/or symptoms.

   ANOTHER FASTER WAY TO TAKE A MEDICAL HISTORY IS BY USING THE KEY WORD "SAMPLE PQRST"

   S: Symptoms
   A: Allergies
   M: Medicine taken
   P: Past history of similar events
   L: Last meal
   E: Events leading up to illness or injury

   P: Provocation/Position - what brought symptoms on, where is pain located.
   Q: Quality - sharp, dull, crushing etc...
   R: Radiation - does pain travel
   S: Severity/Symptoms Associated with - on scale of 1 to 10, what other symptoms occur
   T: Timing/Triggers - occasional, constant, intermittent, only when I do this. (activities, food)

   EXAMPLE:

   S) 21 y/o male c/o sore throat. No known allergies. Taking no meds. Have approx (2) ST per year. Eating and drinking normally. Was fine until yesterday morning when woke up with ST. Denies fevers, chills, sweats, SOB, & HA.

3. Past History (PH)
   1. Other significant illnesses
   2. Prior admissions
   3. History of major trauma
   4. Surgery
   5. Childhood illnesses
   6. Neurological history

4. Family History
   1. This is the pertinent history of diseases of the family within the patients bloodline.
   2. Any disease traced through the family is important. If no history found, note it on SF600.

5. Social History (SH)
   1. Drugs
   2. ETOH
   3. Tobacco
   4. Over the counter medications

6. Marital History
   1. Assist by assessing patients current condition.
   2. May help diagnose an underlying physical or psychological problem.

7. Occupational History (OH)
   1. This is a brief description of the patients job.
   2. This is of importance if the patient works around hazardous materials and chemicals.
8. Systems Review (ROS)
   1. A comprehensive account of complaints, both past and present.
   2. Double check: Recheck your work to prevent omission of significant data.
   3. Diagnosis: a systems review will allow the examiner to group the symptoms and arrive at a logical diagnosis.

   Review of Systems

   1. General
      1. usual weight
      2. weight change
      3. weakness, fatigue, fever
   2. Skin
      1. rashes
      2. lumps
      3. itching
      4. dryness
      5. color changes
      6. hair and nails
   3. Head
      1. headache
      2. head injury
   4. Eyes
      1. vision
      2. corrective lens use; type
      3. last eye exam
      4. pain
      5. redness
      6. tearing
      7. double vision
   5. Ears
      1. hearing
      2. tinnitus
      3. vertigo
      4. pain, earache
      5. infection
      6. discharge
   6. Nose & Sinuses
      1. frequent colds, nasal stuffiness
      2. hay fever, atopy
      3. nosebleeds
      4. sinus trouble
   7. Mouth & Throat
      1. teeth and gums
      2. last dental exam
      3. sore tongue
      4. frequent sore throat
      5. hoarseness
   8. Neck
      1. lumps in neck
      2. pain
   9. Breasts
      1. lumps
      2. nipple discharge
      3. pain
      4. self-exam
   10. Respiratory
       1. cough
       2. sputum (color, quantity)
       3. hemoptysis
       4. wheezing
       5. asthma
       6. bronchitis
       7. pneumonia
       8. TB, last PPD
       9. pleurisy
       10. last CXR
   11. Cardiac
       1. heart trouble
       2. HTN
       3. rheumatic fever
       4. heart murmurs
       5. dyspnea/orthopnea
       6. edema
       7. chest pain/palpitations
       8. last EKG
   12. Gastrointestinal
       1. trouble swallowing
       2. heartburn
       3. appetite
       4. nausea
       5. vomiting
       6. vomiting blood
       7. indigestion
       8. frequency of BM’s, last BM, change in habit
       9. rectal bleeding or tarry stools
       10. constipation
       11. diarrhea
       12. abdominal pain
       13. food intolerance
       14. excessive belching or farting
       15. hemorrhoids
       16. jaundice, liver or gall bladder trouble, hepatitis
   13. Urinary
       1. frequency of urination
       2. polyuria
       3. nocturia
       4. dysuria
       5. hematuria
       6. urgency, hesitancy, incontinence
       7. urinary infections and STD’s
       8. stones (renal calculi)
   14. Genito-reproductive
       1. MALE
          1. discharge from or sores on penis
          2. STD hx and treatment, Last HIV test
          3. hernias
          4. testicular pain or masses
          5. frequency of intercourse, libido, difficulties
       2. FEMALE
          1. 1st menarche, regularity, frequency
          2. flow duration, amount
          3. bleeding between periods or after intercourse
          4. last PAP, results
          5. number of pregnancies, deliveries, abortions (spontaneous & induced)
          6. STD’s hx and treatments, Last HIV test
   15. Musculoskeletal
       1. joint pain/stiffness, arthritis, bachache.
          (describe location and swelling, redness, pain, weakness, ROM)
       2. past injuries, treatments
   16. Neurologic
       1. fainting, blackouts, seizures, paralysis, weakness, numbness, tingling, tremors, memory
   17. Psychiatric
       1. mood, affect
       2. nervousness, tension, depression
       3. past care
   18. Endocrine
       1. thyroid trouble
       2. heat or cold intolerance
       3. excessive sweating, thirst, hunger, urination
       4. diabetes
   19. Hematologic
       1. anemia
       2. ease of bruising, bleeding
       3. past transfusions and any reactions

Hospital Corpsman Sickcall Screeners Handbook

Naval Hospital, Great Lakes

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