THE SOAP NOTE!!!

Ok Nurse Practitioners and NP Students– here we go!!!! The Soap Note!

So as stated on my IG post, the SOAP not is a very important documentation note for us. This note is used to protect us from lawsuits and this note is used for billing purposes as well. Our notes need to be accurate, concise, and organized– being sure to include all pertinent details. The Soap note is broken up into four sections… Can you guess what they are??? Yup! you guess right S-O-A-P

Subjective, Objective, Assessment, and Plan.

Subjective data includes everything you patient tells you!

Chief Complaint: A short Phrase or sentence explaining why your patient came to see you today; i.e. Burning with urination

History of present illness: This is what your patient is explaining to you… (be sure to ask them pertinent questions such as onset of symptoms, duration of symptoms, what makes it better/worse, did they take anything at home to help relieve symptoms….)

i.e.  25 year old female patient presents to clinic today for burning with urination that started two days ago. Patient denies frequency but does feel the urgent need to urinate. She denies any foul odor and denies fever and chills as well. Patient stated she did not take anything at home to help relieve her symptoms. 

Under the subjective data you will also need to Past Medical Hx, Surgical Hx, Family Hx, Social Hx, Allergies, Medications, and Immunizations…

i.e.

Past Medical Hx: HTN

Surgical Hx: Appendectomy (2012)

Family Hx: Mother (Breast CA) Father (CABG) 

Social Hx: Social Drinker, denies smoking, and illicit drug use

Allergies: PCN

Medications: HCTZ 25mg once daily for HTN

Immunizations: Up to date

Lastly you have to include a review of systems (ROS) this too, is subjective data, this is what your patient is telling you.

ROS:

Constitutional: no weakness, fatigue, fever, or night sweats

Eyes: denies eye pain, vision disturbances, and eye pressure

Ear: no pain, no hearing disturbances, tinnitus, or discharge.

Nose: no congestion or discharge, no bleeding, no pain.

Mouth and throat: denies cough. Denies painful or soar throat

Neck: no swollen neck glands.

Respiratory: no cough denies SOB and wheezing, no painful breathing.

Cardiac: No CP, denies SOB, denies palpitations, and denies dizziness.

GI: no n/v/d, denies abd pain, cramping and discomfort. No changes in bowel patterns, no blood in stool

GU: + urgency – frequency, +Burning with urination.

Musculoskeletal: No joint pain, stiffness, or muscle pain

Hematologic: no bruising or bleeding.

Skin: No rash, irritations, or redness

Neurology: No complaints of HA, numbness, tingling, dizziness, or lightheadedness. Denies tremors or involuntary movements.

Mental Health: Denies depression and anxiety.

 

Ok the subjective section is done!!!! On to the objective  section!

The objective section of your note is what you, the practitioner assesses; and measurable data. Your Physical exam will go into this section and it will include your vital signs, BMI, results from tests, imaging, cultures, labs etc…

Objective

BP 132/78, HR 71, RR 17, O2 sat 100%, Temp 98.5, HT 5’2”, Wt 120lbs, BMI 21.95

Urinalysis: +Leuks +Nits – Blood

Physical Exam:

Head: Head and scalp normocephalic, normal hair distribution

Eyes: EOM intact, red reflex visualized, PERRLA, no cateracts noted b/l, eyelids without redness or swelling

Ears: No tenderness on palpation of tragus, no erythema or effusion. Tympanic membrane translucent in bilateral ears.

Nose: No erythema or swelling of turbinates, no discharge and crusting seen in bilateral nares

Throat and Mouth: No Pharyngeal erythema and uvula midline. No ulcers noted. No foul odor from mouth, no tonsillar englargement without exudates. Neck is supple without tender cervical nodes, no nuchal rigidity and thyroid tissue firm pliable and non-tender.

Thorax and Lungs: no cough, B/L BS clear in all fields, respirations are unlabored, no use of accessory muscles. No pain related to respiration

CV: HR NSR, no murmur noted. +Pules in all four extremities. Cap refill <2 sec in all four extremities.

ABD: abd soft/ Lower abd tenderness, no visual peristalsis or palpitations. BS present in all four quadrants. No mass noted

GU: no redness, swelling, or discharge. + pelvic tenderness

MS: Full active ROM, gait balanced and steady. No weakness or atrophy.

Neuro: AOX3, PEERLA, cranial nerves tested and intact. No tremors noted. Memory intact. Deep tendon equal B/L +2

Psych: neat appearance, behavior and speech appropriate. Mood and affect normal and appropriate to situation. Patient is pleasant and cooperative

 

That part wasn’t so bad…. Next is the Assessment portion. The Assessment portion is your diagnosis and your differential diagnosis ( 3 of them ) What do you think my patient has….??? Yup you’re right,a UTI!

Assessment 

25 year old female presents with complaints of burring with urination, and urinary urgency. Pt afebrile and Pt tested positive for UTI- UA shows +Leuks +Nit. 

Diagnosis: Urinary Tract Infection

Differentials: Bacterial vaginosis, Yeast infection, Vaginitis due to trichomonad , Over active bladder. (Your differentials are likely disease processes that you have been able to rule out, or that you may expect but are less likely due to your subjectives and objectives)

 

Lastly! Your Plan!!! How do you want to treat your patient… Also you must add education to this section!

Plan:

-Bactrim 

-160 mg trimethoprim/800 mg sulfamethoxazole by mouth every 12 hours for three days.

-Increase fluid intake 2liters per day 

-Proper hygiene- wipe front to back to avoid bacteria/pathogens from entering urethra

Education:

Complete full dose of antibiotics even if symptoms have resolved

Take antibiotic with food to avoid stomach irritation

Take also with a full glass of water

*Follow up with PCP in one week

If symptoms worsen or you develop a fever (>100.4) go to the emergency room 

 

 

And thats it!!! You need to be sure to include education in your plan. Try to avoid medical terminology in this section because your patient will take home these very instructions and you as the Provider want to be sure they understand and can follow your instructs!!!

 

Thats the SOAP! Please leave a comment if this was helpful! 🙂