11/13/24, 7\:41 PM Guide | SOAP documentation

SOAP documentation

Table of contents

Introduction

Documenting a patient assessment in the notes is something all medical students need to practice. This guide discusses the
SOAP framework (Subjective, Objective, Assessment, Plan), which should help you structure your documentation in a clear and
consistent manner.

Subjective

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.
As part of your assessment, you may ask\:
"How are you today?"
"How have you been since the last time I reviewed you?"
"Have you currently got any troublesome symptoms?"
"How is your nausea?"
words.
If the patient mentions multiple symptoms you should explore each of them, having the patient describe them in their own
You should document the patient's responses accurately and use quotation marks if you are directly quoting something the
patient has said.

Objective

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

Objective observations

Appearance
Document the patient's appearance (e.g.
" T h e p a t i e n t a p p e a r e d t o b e v e r y p a l e a n d i n s i gn i
" ).
Vital signs
Document the patient's vital signs\:
Blood pressure
Pulse rate
Respiratory rate
SpO 2
(also document supplemental oxygen if relevant)
Temperature (including any recent fevers)
Fluid balance
An assessment of the patient's
Oral
Nasogastric
Intravenous
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Urine output
Vomiting
Drain output/stoma output
Clinical examination
Some examples of clinical examination
" W i d e s p r e a d e x p i r a t o r y w h e e z e o n a u s c u l t a t i o n o f t h e c h e s t .
"
" T h e a b d o m e n w a s s o f t a n d n o n-t e n d e r .
"
" T h e p u l s e w a s i r r e g u l a r .
"
" T h e r e w e r e n o c r a n i a l n e r v e d e
"
Investigation results
Some examples of investigation results include\:
Recent lab results (e.g. blood tests/microbiology)
Imaging results (e.g. chest X-ray/CT abdomen)

Assessment

The assessment section is where you document your thoughts on the salient issues and the diagnosis (or di
diagnosis), which will be based on the information collected in the previous two sections.
Summarise the salient points\:
" P r o d u c t i v e c o u g h ( g r e e n s p u t u m )"
" I n c r e a s i n g s h o r t n e s s o f b r e a t h"
" T a c h y p n e a ( r e s p i r a t o r y r a t e 2 2 ) a n d h y p o x i a ( S p O 2
8 7 % o n a i r )"
" R i g h t b a s a l c r a c k l e s o n a u s c u l t a t i o n"
" R a i s e d w h i t e c e l l c o u n t ( 1 5 ) a n d C R P ( 8 0 )"
" C h e s t X -r a y r e v e a l e d i n c r e a s e d o p a c i t y i n t h e r i g h t l o w e r z o n e , Document your impression of the diagnosis (or di
c o n s i s t e n t w i t h c o n s o l i d a t i o n"
" I m p r e s s i o n \: c o m m u n i t y-a c q u i r e d p n e u m o n i a"
If the diagnosis is already known and the
on whether the patient is clinically improving or deteriorating\:
" O n d a y 3 o f t r e a t m e n t f o r c o m m u n i t y-a c q u i r e d p n e u m o n i a"
" R e d u c e d s h o r t n e s s o f b r e a t h a n d i m p r o v e d c o u gh"
" O x y g e n s a t u r a t i o n s 9 8 % o n a i r , r e s p i r a t o r y r a t e 1 5"
" C R P d e c r e a s i n g ( 2 0 ) , w h i t e c e l l c o u n t d e c r e a s i n g ( 1 1 )"
" I m p r e s s i o n \: r e s o l v i n g c o m m u n i t y-a c q u i r e d p n e u m o n i a"

Plan

The
issues raised during the review.
Items you to include in your plan may include\:
Further investigations (e.g. laboratory tests, imaging)
Treatments (e.g. medications, intravenous
Referrals to speci
Review date/time (e.g.
" I w i l l r e v i e w a t 4 p m t h i s a f t e r n o o n .
" )
Frequency of observations and monitoring of
Planned discharge date (if relevant)
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