Transcript - Twiggs County High School

Nutritional Progress Notes
Objectives
After this presentation, you will be able to:
State the descriptive words for the acronym SOAP
2. Give a brief description of the meaning for each
word in the acronym SOAP
3. Write a progress SOAP progress note from a case
study
1.
What is a SOAP Note?
 Summary report of client’s/patent’s condition
 Written in client’s/patient's chart
 Acronym for
S
= subjective
 O = objective
 A = assessment
 P = plan
Pros and Cons of SOAP Charting
PROS
CONS
 Common use by nutrition
 Can encourage lengthy chart
care professionals and other notes
medical disciplines
 Some physicians are less
 Taught in most dietetics
likely to respond to this
education programs
format than others
 Easy to learn and utilize
 Can downplay continued
reevaluation of client’s
progress
 Emphasizes legitimacy of
objective over subjective data
S: Subjective
Information provided/spoken by patient, family, or
other person.
 Pertinent socioeconomic, cultural info
 Level of physical activity
 Significant nutritional history: usual eating pattern,
cooking, dining out
 Work schedule
O: Objective
Factual and reproducible observations.
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Diagnosis
Height, age, weight—and weight gain/loss patterns
Lab data
Clinical data (nausea, diarrhea)
Diet order
Medications
Estimation of nutritional needs
A: Assessment
Summary of dietitian's professional nutrition
diagnosis or clinical thoughts.
 Interpretation of patient’s status based on subjective
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and objective info
Evaluation of nutritional history
Assessment of laboratory data and medications
Assessment of diet order
Assessment of patient’s comprehension and
motivation
P: Plan
Describes the scope of Treatment and
contains the action plan and prognosis.
 Diagnostic studies needed
 Further lab work or lab data needed
 Medical nutrition therapy goals
 Education nutrition plans
 Recommendations for nutritional care
 Date for any follow-up
Sample SOAP Note
Subjective
S: works second shift, eats two meals a day,
before/after shift; usually eats in fast food
restaurants (fried foods, burgers, ice cream)
for lunch and dinner. Does not add salt to
foods. Takes blood pressure 2x/day.
Activity: Plays volley ball on weekends
Sample SOAP Note
Objective
O: 34 y.o. female; last menstrual period =
01/05/2006; iron level= 12.3; history of
hypertension x 2 years; blood pressure =
130/85 for last four readings; height = 5ft.
3in; weight: 205 lb; BMI=36.
Sample SOAP Note
Assessment
A: obese; hemoglobin level normal; excessive
sodium intake (NI-5.10.2) related to
frequent use of fast food meals as evidenced
by diet history. Blood pressure high/normal.
Low physical activity.
Sample SOAP Note
Plan
P: Reviewed DASH diet. Identified foods to
pack from home to eat during
lunch/dinner. Discussed non-food
rewards to purchase with money saved
from not eating out when weight and B/P
goals are reached. Encouraged more
activity to facilitate weight loss. Next
appointment = 30 days from today.
Conclusion
 Not all the parts are used at every visit
 Complete sentences are not necessary
 Signature goes at end of last line
 Never leave a blank line between entries
 Never leave a half filled line. Draw a line to fill the
line.
Lecture Quiz
1.
What does the acronym SOAP stand for and
give a brief description of the meaning for each
word.
2.
What medical professionals usually use SOAP
notes?
3.
Name one advantage and one disadvantage to
using SOAP progress notes.
Lecture Quiz

Write a progress SOAP progress note using the
following case study:
Your second appointment for the day is with a
25 year old Chinese male. He states he was
told by his doctor that his cholesterol is high
and he should to “eat better” but he is confused
as to how to do that. He hands you a paper
with the following labs on it: height = 67”;
weight = 200#; blood pressure = 120/80; total
cholesterol = 150 and LDL levels= 160.