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Sample SOAP Notes

The document provides a detailed example of SOAP notes for both medicine and surgery, highlighting the subjective, objective, assessment, and plan components. It includes patient observations, vital signs, physical examination findings, and treatment plans for conditions such as CHF, HTN, and DMII. The surgery section emphasizes post-operative assessments and considerations for patient care, including pain management and diet progression.

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2 views2 pages

Sample SOAP Notes

The document provides a detailed example of SOAP notes for both medicine and surgery, highlighting the subjective, objective, assessment, and plan components. It includes patient observations, vital signs, physical examination findings, and treatment plans for conditions such as CHF, HTN, and DMII. The surgery section emphasizes post-operative assessments and considerations for patient care, including pain management and diet progression.

Uploaded by

elfranz917
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

SOAP Notes

Sample Medicine SOAP

S: No SOB/CP overnight. 3 pillow orthopnea (improved from 4 at admission). Pt feels


swelling in feet has improved but still has to elevate legs frequently. Pt walked halls s
difficulty but did not tolerate steps.

O: T-98.6 Tm-99.3 HR-87 RR-14 BP- 114/69-129/78


I/O1800cc/4500cc FSBS 178-223

PE: GEN – A&O x 3, in NAD


HEENT – PERRL, EOMI
CV – RRR, S3 present, no m/r/g, 2+ PE to mild calf
RESP – CTAB x mild crackles @ bases, breathing symm c normal effort
ABD – s/nt/nd, NABS, no HSMeg, no palpable masses
MS – MAEW, 5/5 strength UE/LE
NEURO – CN II-XII intact, normal sensation to LT/pressure/temp, two-point
discrimination intact, gait normal, patellar and brachiorad DTRs 2/4
PSYCH – affect, mood congruent and appropriate

Labs: CBC, BMP or CMP

Imaging: XR, CT, Echo, etc.

A/P: 68 yo WM c CHF, HTN and DMII admitted for edema and DOE
1. CHF – previously class II but pt now symptomatic c mild exertion; echo scheduled
today to eval EF/cardiac fxn; pt on appropriate CHF regimen at home; will continue
aggressive diuresis c Lasix and consider addition of Digitalis at this time; cont low Na diet
2. HTN – currently on Lasix, BB and ACEI c good control, cont home meds
3. DMII – on glucophage at home c FSBS in 250-300 range; on SSI c FSBS 178-223 in
house; will consult DM Ed to educate pt on diet/exercise as well as recommend more
appropriate home regimen; cont Q6H FSBS.
Surgery SOAP

S: If post-op, always ask about incisional pain, flatus, bowel movements, urination (if no
foley), any nausea/vomiting, response to pain meds (# of times PCA was admin.), if
eating, whether tolerating PO well, and activity/ambulation.

O: Vitals: Tm, Tc, HR, RR, BP, PulseOx (if applies)


[List UOP for last 24h in 8h intervals, ask your resident whether they like most recent
shift first or last]
Similar to I/O, record drain outputs for last 24h in 8h intervals. PE: (important to
examine the following)

Lungs: clear to auscultation?


CV: any new murmurs?
ABD: bowel sounds? (esp. if post-op b/c BS is an important deciding factor in when to
advance diet)
Incision: clear, dry, and intact? (C/D/I). Good granulation? Ext: any edema?

Labs/Studies/Imaging/Path:
A/P: Brief statement of overall impression. Always include post-op day

(Day of Surgery is POD#0; next day is POD#1). A/P similar to medicine SOAP. Plan should
be to the point!
Include pain control, diet, PT/OT, f/u.

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