Guidelines and Examples on the SOAP Format for Chart Notes

Guidelines and Examples on the SOAP Format for Chart Notes

Guidelines

TheSOAPFormat:ThebenefitsoftheSOAPformatarethatitcanbetailoredtoanytypeof studyorstudyvisitandthat,ifdoneproperly,willsatisfyboththe medicalrecordneedsforthe continuingcareoftheclientandthesourcedocumentationrequirementsforthestudy.Belowisa broaddefinitionofthecomponentsoftheSOAPformatandthenthreeexamplesofhowitmight be usedinspecificscenarios.

•S(SUBJECTIVE):Thesubjectivecomponentistheclient’sreportofhowheorshehas

beendoingsincethelastvisit,andthisincludesthecurrentvisit. Subjectivecommentsmade by clientmayrangefromnocomplaints(“Ifeelgreat”)tospecificcurrentcomplaints(“I’ve hadaheadachefor3days”)tocomplaintsthattookplaceintheinterimbuthaveresolved(“3 weeksagoIhaddiarrheaforacoupleofdays”). Foraninfant’srecord,thesubjective componentwouldincludethemother’s(orcaretaker’s)observations.Again,thesemayrange fromnocomplaints(“Thebabyishappyandhealthy”)toaspecificcurrentcomplaint(“the baby’sbeenfussylately”)toacomplaintthathasresolved(“thebabyhadanappyrash,but it’s allbetternow”).Theclientshouldbeaskeddirectedquestionsaboutanycomplaints– currentorreportedlyresolved--andaskappropriatefollow-upquestionsanddocumentall responses.

Reportsofcompliancewithspecifictreatmentregimens–whetherstudy-relatedornot– shouldalsobeincludedhere:“Howmuchofyourstudymedicationdidyoutakesinceyour lastvisit?Didyoumissanydoses?Why?”or“Atthelastvisit,youweregivenantibiotics forpneumonia.Doyouhaveanypillsleft?”

•O(OBJECTIVE):Theobjectivecomponentisstraightforwardandincludesvitalsigns (temperature,bloodpressure,pulse,respiration),documentationofthephysicalexamination thatwasdone,andresultsoflaboratoryorotherstudiesthatmaybedoneduringthecourseof thisvisit.Foraclientwithnocomplaints,thephysicalexammaybelimitedtomeetstudy- specificneeds.Foraclientwithacomplaint,anappropriatefocusedphysicalexamshouldbe completedinadditiontoorinsteadofthestudy-specificexam.

•A(ASSESSMENT):Forthiscomponent,theclinicianpullstogetherthesubjective informationgatheredduringtheinterviewwiththeclientandtheobjectivefindingsofthe physicalexam(and,possibly,laboratoryorotherstudyresults)andconsolidatesthemintoa shortassessment:“Thisisa26-yearoldwomanhereforaroutineHPTNmicrobicidestudy visit;therearenoclinicalproblemstoday”or“Thisisa22-yearoldpregnantwoman,26 weeksgestationbyphysicalexam,hereforanon-studyvisitduetochiefcomplaintof increasednauseafor1weekandvomitingfor2days”or“Thisisa46-yearoldHIV-infected manhereforroutineHPTNstudyvisitwithincreasedfatigueandpallor;bloodsmearis positiveformalaria.”

•P(PLAN):Theplanshouldincludeanythingthatwillbedoneasaconsequenceofthe assessmentandcouldinclude:

oThecollectionofstudy-specificlabsorspecialstudies

oThecollectionoflabsorspecialstudiestoaddressanacutecomplaint

oIntentiontoadmittothehospital

oStudy-specificmedicationsdispensed(nameofdrug,amountdispensedanddosing instructions)

oNon-studymedicationsprescribedordispensedforaspecificacuteorchroniccomplaint

(nameofdrug,amountdispensedanddosinginstructions)

oFollow-upinstructionstotheclient(forexample:“returntotheclinicifthisproblemdoes notresolve”)

oDateofnextappointment

ExamplesofSOAPNotes

FollowingarethreeexamplesofSOAPnotes.Case1isaparticipantinasubstanceusestudy; Case2isaparticipantinanantiretroviralstudyandCase3isaninfantinaperinatalstudy.

•Case1:participantinasubstanceusestudy

Reasonforvisit:36-yearoldmanhereforaroutinestudyvisitforHPTNIVDU

S:Mr.Rreportsthathehasbeenwellsincethelastvisitandhereportsnocomplaintstoday. Hestatesthathehasnotusedanydrugssincethelastvisit,includingIVdrugs.

O:T:37C (bymouth);BP:130/68;P:70;R:14.

Examofarms:wellhealedlinearscarsalongtheantecubitalarea.

A:36-yearoldmanenrolledinHPTNXYZ.NoevidenceofcurrentIVdruguse.

P:Continuewithcounselingsessions.ClientisscheduledtoreturnforVisit7onOctober

12.Clientalsoremindedtocontactorreturntotheclinicishehasanyproblemsbeforethen.

•Case2:participantinanantiretroviralstudy

Reasonforvisit:24-yearoldHIV-infectedwomanhereforvisit3ofHPTNARV.

S:Clientreportsthatthe“rash”inhermouthnotedatthelastvisitgotbetterwiththe treatment(nystatintroches)andthatshecompletedalldoses.Shehasnocomplaintstoday. Shereportsthatshehasnotmissedanydosesofherstudymedications(CombivirandNVP). Shedeniesanyrash,headacheortinglingofherextremities.Shestatesherappetiteisgood. InformedclientthatherCD4countsfromthelastvisithavecontinuedtoincreaseandare now 265.Sheexpressedhappinessatthisnews.

O:T:37C (bymouth);BP:110/60;P:64;R:12;wt:54.5kg

Thinbutwellnourishedappearingwoman. Skin:Norashesnoted

HEENT:Oralmusosapink,moist;noexudate

Lymph:Palpablenontendercervical,axillaryandinguinallymphnodes

Cardiac:Rhythmregular;no murmurs

Pulmonary:Norales,rhonchi,wheezing.

Abdominal:Nohepatomegaly;spleenisnontenderandpalpable4cmbelowleftcostal margin.

GU:Notdone.

Neuro:Gaitnormal.Orientedtoperson,placeandtime.

A:24-yearoldHIV-infectedwomandoingwellonprotocolARVSwithanincreaseinCD4 countanda .5kgweightgainsincethelastvisit.Oralthrushnotedatlastvisitresolvedwith

5-daycourseofnystatintroches.Generalizedadenopathyandspenomegalyareunchanged frompreviousexams.

P: 1.Study-specificlabs:CBCwithdifferentialandLFTs

2. Imonthcourseofstudydrugsdispensed:combivir(150mglamivudine;300mg zidovudine),1tabmorningandnight,66dispensed;NVP(200mg),1tabmorningand night;66dispensed.

3. Returnforvisit4foronMarch1.

4. Clientalsoremindedtocontactorreturntotheclinicisshehasanyproblemsbeforethen.

•Case3:participantinanperinatalstudy

Reasonforvisit:Motherandbabyhereforasickvisitbecausebabyhas“pneumonia”

S:Thisisa 4-montholdinfantenrolledonHPTNPMTClastseen2weeksagoforaroutine protocolvisit.Motherreportsthat,about1weekafterthelaststudyvisit,thebabystarted “coughingconstantly.”Motherreportsthatthecoughinghasnotinterferedwiththebaby’s eating(babyhasbeenweanedandisbeingcupfed);shedeniesthatthebabyhasfelthotto touchduringthisperiod;shestatesthatbaby’sactivityisthesameasbeforethecoughing began.Perthemother,everyoneinthefamilystartedcoughingaroundthesametimeasthe babyalthoughnooneseemsill.Shedoesnotethatallofthecoughingseemsrelatedtothe excessofdustintheairsincetheconstructionofthenewroadinfrontofherhousebegan.

O:T:37C(rectal);BP:110/60;P:72;R:14;wt:6kg;length:62cm

Well-developed,well-nourishedfemaleinfantinnoobviousdistress.Blanketsarenotedto bequitedusty.

HEENT:Oralmucosapink,moist;noexudatesorredness

Lymph:Noadenopathy

Cardiac:Rhythmregular;no murmurs

Pulmonary:Noretractionsoreffortwithrespiration.Norales,rhonchiorwheezing

Abdominal:Notdone

GU:Notdone

Neuro:Notdone

A:4-montholdinfantwithcoughingsecondarytoairbornedust

P:Motheradvisedtocoverthewindows(closingthecurtainsmightbesufficient), particularlythosewindowsfacingtheconstruction.Alsorecommendedthatmotherkeepthe babyintheroomfarthestfromtheconstruction.Iftheproblempersistsorworsens,she should returntotheclinicimmediately. Motherremindedofbaby’snextstudyappointment onJuly24th.