Transcript SOAP Notes - Dr Ted Williams

SOAP Notes
Health Care Documentation
Heather Peterson
October 10, 2005
Documentation
 Cases for oral health care
 Interview and Counsel patients
 Write a SOAP note about the interaction
 Can use SOAP checklist on Blackboard
 Present to class
Header
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Patient name
Age
Chief complaint
Allergies
 Can see these as a header at the
beginning of the SOAP note or within the
S and O parts.
Subjective
 Written in full sentences, paragraph form.
 Identify patient and give brief description of
encounter
 Mrs. Johnson, a 47 yo woman, presents to the
pharmacy with a question about canker sores.
 State patient’s complaints
 One sentence in patient’s words
 “I keep getting these painful white dots in my mouth. How
do I treat them?”
 8 attributes
 Histories if pertinent: PMH, FH, SH
Subjective example
Sylvia York
DOB: 1/27/76
CC: headache
NKDA
S-Sylvia York, a 27 year old female presents to the pharmacy asking about
treatments for a headache. She has throbbing pain on the right side of
her head, accompanied by some nausea, photophobia and phonophobia.
She rates the pain 7 out of 10. She has been diagnosed with migraines 3
years ago but didn’t start having them often until a few months ago. She
has had 3 in the past 2 months. She usually takes 2 Tylenol PM and
sleeps through the pain in a dark, quiet room. The headaches typically
last 4 to 6 hours. She cannot do that this time because she recently
started taking night classes and has to stay up tonight to study for a test.
Sylvia is currently taking Ortho Tri-Cyclen. She has been taking samples
for the past 4 months given to her by her doctor. She does not take any
other Rx drugs, OTC drugs or supplements. She does not smoke or drink
alcohol. She drinks 2-3 caffeine drinks a week.
Objective
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Written in list format typically.
Allergies
Medications (Rx, OTC, supplements, herbal)
Physical exam: vital signs, any physical
assessment (describe patients appearance)
 Patient has a flat, oval ulcer with erythematous
tissue around it on the right inner cheek.
 Pertinent labs, test results (not usually in
community setting)
Objective example
 O – Sylvia appears healthy, but somewhat
stressed and uncomfortable
 Medical dx:
Allergies:
Migraines
NKDA
 Medications:
Ortho Tri-Cyclen Lo4/30/02 to 5/25/05
Ortho Tri-Cyclen samples since 05/25/05
 B.P: 116/74 mm Hg
Assessment
 Written in full sentences, paragraph form.
 All issues in S & O addressed in A
 Supporting data for assessment should be found in S & O
 Organize, prioritize by disease state, complaint, drug
related problem
 State the problem, disease, etc – justify decision by
discussing other options and how you reached
conclusion.
 Goals for treatment
 Justify recommendations – discuss other options and
why option chosen
 Safety, tolerability, efficacy/evidence, price, simplicity
Assessment Example
A –. Based on the location of the headache, the severity of the pain and the associated
sx it is likely the patient has a migraine HA. Tension HA was ruled out because of
the location and severity of the HA. Rebound HA was ruled out because the
patient does not take analgesics regularly or drink caffeine regularly. An increase
in the frequency of the headaches is associated with a change in oral
contraceptives. The newer formulation, Ortho Tri Cyclen, has a higher dose of
estradiol, which has been documented to increase the frequency and severity of
migraine headaches. The goals of treatment are to alleviate the acute pain,
restore normal functioning so the patient can study, and prevent relapse. It is
recommended she speak with her PCP about her increase in migraines since
switching to Ortho Tri Cyclen. Extra Strength Tylenol (acetaminophen 500 mg) 2
q4-6h prn pain is recommended to treat the current migraine. The patient has
taken Tylenol PM (acetaminophen 500 mg and diphenhydramine 25 mg) in the
past and said it worked. Extra Strength Tylenol has the same analgesic without the
antihistamine, diphenhydramine which may make her drowsy. Other OTC
analgesics may be effective. Since she does not drink alcohol or have a history of
liver disease, she does not have any contraindications to acetaminophen.
Successful use of acetaminophen of the past makes it a reasonable initial choice
for self-treatment.
Plan
 Written in brief sentences, concise and
complete.
 Provides actions to be taken based on A,
includes treatment, monitoring, education.
 Medication recommendation: drug, dose, route,
frequency, duration.
 Monitoring: efficacy and toxicity parameters,
timeframe for effect, precautions, SE.
 Follow-up
Plan example
P –Sylvia is to take 1-2 acetaminophen 500 mg tablet every 4-6 hours
as needed for migraine HA pain, NTE 4000 mg (8 tablets) in 24
hours. The medication should take effect within 1 hour. She is not
to drink alcohol while taking the medication or take any other
acetaminophen containing products during this time. It is also
recommended that she use an ice pack on the location of the pain
and study in a quiet room. In the future she should keep a HA
diary to try to identify migraine triggers. She is to meet with her
PCP to discuss the increase incidents of migraines in the past few
months. She will call the pharmacy to report on the efficacy of the
chosen therapy..
Closing
 Sign name and title
 Date
All sections
 Written in ink (black or blue)
 Abbreviations and symbols can be used
 Mistakes are crossed out with a single
strike and initialed.
 Legal document!
 Never write offensive or accusatory
statements
 Grammer and spellling
Clinic SOAP example
Patient Name: Robert Dreg DOB: 09/17/1967
Record No. D-679dk978
Date: 12/4/99
S—Pain in left hip x 3 months; worse when walking or doing exercise.
NKDA.
O—Wt. 195 lb, Ht. 5'5'', normal ROM both hips, no swelling or
redness.
A—Possible osteoarthritis; R/O rheumatoid arthritis
P—bloodwork—sed rate, rheumatoid factor, x ray L hip PA and
lateral; ibuprofen 600 mg t.i.d po; recheck 2 months.
------------------------------------------------------- Bob Ridman, CCMA
Brenda D. Fleiss, MD