REVIEW OF THE SOAP NOTE
SOAP notes are narrative, predictably organized, problem oriented
progress/office notes. They are NEVER intended to replace a full history and
physical. The intent is for a logical approach to document each problem a patient
has and to provide documentation for how you will handle it and follow up on it.
The format of the note is as follows:
Subjective
Objective
Assessment
Plan
The Subjective section contains a complete description of the patient's
description of symptoms as well as progress from the last encounter. This may
be very short if the patient was seen the day before and there is not much
change in status, or quite long depending on the situation. It may resemble a HPI
(History of Present Illness) with all pertinent positives/negatives, pertinent PMH,
etc.
The Objective section contains the following data: VS, PE, lab results, Xray results, diagnostic test results and current medications.
and
There are two methods for the documentation of the
Assessment and Plan. The key to both is a full discussion of the differential
diagnosis of each problem (including a rationale for the differential) and
documentation of the plan and time parameters for f/u.
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
The first is to recap the patient in one or two sentences and then write out a
complete discussion of the differential diagnosis. Below this would be a
numbered list of each patient problem with the plan (meds, tests, labs,
counseling etc.) and f/u plan and time parameter for the follow up.
The second method lists each problem with an individual discussion
assessment and follow up plan.
REVIEW OF THE SOAP NOTE
The SOAP note should include the following:
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
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a differential diagnosis (for new sx)
a rationale for the differential
medications prescribed
note that side effects of medications were discussed - documentation
of patient education
follow up interval noted warnings regarding complications of condition
warranting re-contact
A "gold-standard" SOAP note will have a differential (if the problem is as
of yet undiagnosed) and a brief discussion of the rationale for the differential
diagnosis. You should use this format during this clerkship, and after.
Examples of SOAP note formats:
First Style:
S:
Ms Smith, 25 year old female, presents to the office with a complaint of
right lower quadrant pain increasing in intensity over the last 12 hours. She
states she was well until around 8PM last evening when she developed a dull
achy pain in the periumbilical region which shortly localized to the right lower
quadrant. It has increased in intensity gradually through the night and she
thinks that she slept very little. There is no radiation.
She is slightly nauseated but has had no vomiting, diarrhea, cramping,
flatulence or dysuria. She and her boyfriend had leftover chicken last night
for dinner and he shows no signs of illness. She has no appetite this morning.
Her LMP was 2 weeks ago with her last period being light but otherwise
normal. She has had no bleeding since. Ms Smith uses condoms only for
birth control and is in a monogamous relationship.
Her boyfriend has no history of or symptoms of a sexually transmitted
disease. She has not traveled in two years and currently works as a
computer analyst in a small information technology company.
Her only med is a MVI daily. She smokes 1PPD and does not use other drugs
or alcohol. She has had no previous surgery.
REVIEW OF THE SOAP NOTE
O:
HEENT:
Lungs:
Cor:
Abd:
Rectal:
Pelvic:
Extremities:
tired and anxious appearing woman
T: 100, FP:90, BP:110/70
Pale, slightly dry mucous membranes
Clear
Regular rate and rhythm with no murmurs, gallops or rubs
Occasional bowel sounds, tender right lower quadrant with
slight rebound tenderness, no palpable masses, no
hepatosplenomegaly/. No CVA tenderness
no tenderness, quaiac negative
Cervix appears normal with no obvious d/c. Tenderness
without mass or fullness in the R culdesac with mild
cervical motion tenderness
Normal
Neurologic Exam Screening normal
A:
Ms Smith presents with RLQ pain of 12 hour duration. She
has tenderness and slight rebound with tenderness in the
R culdesac as well and a low grade fever. Possibilities
include acute appendicitis, R ovarian torsion,
middleschermz, ectopic pregnancy, PID , or a viral
syndrome. Given the lack of d/c and the very minimal
cervical motion tenderness PID is less likely. Ovarian
torsion is a possibility although the pain has been so
constant and with torsion there can be an intermittent
quality. Middleschermz and viral syndromes are diagnosis
of exclusion. With the lack of urinary symptoms or CVA
tenderness it is unlikely that she has UTI of pyelonephtitis.
P:
#1 Abdominal Pain: Obtain CBC with differential, UA, stat
urine pregnancy test (if negative send blood for HCG) .
Obtain surgical consult for pain with rebound
#2 Contraception: Will make appointment to see patient
when out of acute situation to discuss other options for
birth control in addition to condoms.
#3 Tobacco abuse: will discuss at f/u visit for #2
REVIEW OF THE SOAP NOTE
Second Style:
S: Ms Smith, 25 year old female, presents to the office with a complaint of
right lower quadrant pain increasing in intensity over the last 12 hours. She
states she was well until around 8PM last evening when she developed a dull
achy pain in the periumbilical region which shortly localized to the right lower
quadrant. It has increased in intensity gradually through the night and she
thinks that she slept very little. There is no radiation.
She is slightly nauseated but has had no vomiting, diarrhea, cramping,
flatulence or dysuria. She and her boyfriend had leftover chicken last night
for dinner and he shows no signs of illness. She has no appetite this morning.
Her LMP was 2 weeks ago with her last period being light but otherwise
normal. She has had no bleeding since. Ms Smith uses condoms only for
birth control and is in a monogamous relationship.
Her boyfriend has no history of or symptoms of a sexually transmitted
disease. She has not traveled in two years and currently works as a
computer analyst in a small information technology company. Her only med
is a MVI daily. She smokes 1PPD and does not use other drugs or alcohol.
She has had no previous surgery.
O:
HEENT:
Lungs:
Cor:
Abd:
Rectal:
Pelvic:
Extremities:
tired and anxious appearing woman
T: 100 F, P:90 BP: 110/70
Pale, slightly dry mucous membranes
Clear
Regular rate and rhythm with no murmurs, gallops or rubs
Occasional bowel sounds, tender right lower quadrant with
slight rebound tenderness,no palpable masses, no
hepatosplenomegaly/. No CVA tenderness
no tenderness, quaiac negative
Cervix appears normal with no obvious d/c. Tenderness
without mass or fullness in the R culdesac with mild
cervical motion tenderness
Normal
Neurologic Exam Screening normal
REVIEW OF THE SOAP NOTE
A&P:
#1 Abdominal Pain: Ms Smith presents with RLQ pain of
12 hour duration. She has tenderness and slight rebound
with tenderness in the R culdesac as well and a low grade
fever. Possibilities include acute appendicitis, R ovarian
torsion, middleschermz, ectopic pregnancy,PID, or a viral
syndrome. Given the lack of d/c and the very minimal
cervical motion tenderness PID is less likely. Ovarian
torsion is a possibility although the pain has been so
constant and with torsion there can be an intermittent
quality. Middleschermz and viral syndromes are diagnosis
of exclusion. With the lack of urinary symptoms or CVA
tenderness it is unlikely that she has UTI of pyelomephtitis
1. Obtain CBC with differential, UA, stat urine pregnancy
test (if negative send blood HCG)
2. Obtain surgical consult for pain with rebound
#2 Contraception: Will make appointment to see patient
when out of acute situation to discuss other options for
birth control in addition to condoms.
#3 Tobacco abuse: will discuss at f/u visit for #2