The SOAP Note and Presentation Use the SOAP Format for all Oral Presentations and Notes
z Sometimes the term “SOAP” note is only applied to
short notes but the format is used throughout medical practice for communication. SOAP Notes
z Includes information you have learned from the
patient or people caring for the patient. SOAP Notes
z This section includes observations and
measurements that you have made during the physical examination.
z Includes a general description of the patient.
z Results of diagnostic testing also go here. SOAP Notes
z What do you feel is the patient’s differential
z This is organized by problem or organ system. SOAP Notes
z For each problem what diagnostic testing will you
The Complete Patient Evaluation
Used for new patients in hospital or clinic
Complete story of their illness and medical history
The Progress Note
z Daily evaluation of a hospitalized patient
The Complete History and Physical
z Use the similar format for the complete
The Complete History and Physical The Complete History and Physical
z Problem list with differential diagnosis for each
z The assessment and plan may be combined
Sample SOAP note
z Jennifer Myles is a 25 year old healthy single
store manager complaining of right facial pain. She felt well until about three weeks ago when her allergies started acting up. At that time she had itchy watery eyes and a runny nose. She used an over the counter “Tylenol allergy” medication which gave her some relief but her nasal congestion persisted.
Sample SOAP Note
z About two weeks ago her right cheek started to hurt.
The pain is 5/10 in severity and worse with leaning her head down, smiling and chewing. The over the counter medicine is no longer helping.
z She has not taken her temperature but felt she may
have had a fever. She no longer has a runny nose, it just feels congested. She has no sore throat, no headache, no ear pain and no cough. Symptoms are not worse at any time of day or in any particular location. No one at work or at home has been sick. Sample SOAP note
z General: Fatigued appearing young woman
z HEENT: Face: Right maxillary tenderness. No sinus
transillumination on the right side. No conjunctivalinjection. Oropharynx: pink mucus membranes without tonsillar exudates. Nasopharynx: thick green mucous and erythematous turbinates. Ears: tympanic membranes pearly grey with a sharp light reflex. Sample SOAP Note Objective (continued)
z Lungs: Clear to auscultation and resonant to
Sample SOAP Note
z Treat with amoxicillin 500 mg three times a day and a
decongestant as needed for one week. Follow up if symptoms have not improved.
z Fluticasone nose spray for allergy symptoms when
z Used for communication between clinicians.
z Should be a well-organized vignette that
captures the patient and his or her clinical problem.
z Your goal is to help your listeners to visualize the
z Be sure to present information in the correct
z Don’t forget that you are telling a story; try to
z Err on the side of saying less, listeners can
The Presentation The Presentation
z “Chief complaint: Shortness of breath. Mr. Smith is an 84
year retired dentist with a history of hypertension who has new shortness of breath and lower extremity edema.”
z “Mrs. Brooks is a 49 year old teacher with a history of
fibrocystic breast disease who is anxious about a new tender breast lump.”
The Presentation Presentations
z For a new patient you will need to present the complete
z For a follow-up patient in clinic you will need to present
active problems and the chief complaint.
z For a follow-up patient in the hospital you will need to
present the status of the patient’s active problems and any new concerns.
z Include pertinent positives and negatives in the history and
z The more you do the more natural it will become.
z Remember to keep things in the right order.
z Watch others, begin to develop role models. Remember
z Not every doctor will write notes the same
abbreviations because they may cause misunderstandings and even medical errors.
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