SOAP NOTE (PROGRESS NOTE)

INSTRUCTIONS:

1. The SOAP note is to be done for a patient you have seen.

2. The SOAP must be in your own words and may not be pulled forward from an EMR
system or anyone else’s note. (See Academic Integrity and Student Honor Code in
Syllabus). Do not use the phrasing “normal” or “WNL (within normal limits)”; instead,
describe the findings and document the actual results of diagnostics.
3. You can type your findings directly into this template. The space provided is not an
indication of the amount of documentation expected. Please edit the instructions and
commentary on the document you submit for grading. Refer to the grading guidelines for
evaluation criteria.

STUDENT NAME: DATE OF SOAP

SUBMISSION:

PATIENT INITIALS: J.S. DOB: AGE: SEX: RACE:

PATIENT ADMISSION DATE: SOURCE OF INFORMATION:

Patient, Chart

ADMISSION DIAGNOSIS: HOSPITAL DAY:

LOS/POD

DATE OF SOAP: The date the student saw and assessed the patient

 SUBJECTIVE:
 HPI - My patient is a 61-year-old woman. She was brought in after losing
consciousness following elective abdominal surgery. After the surgery, she
showed signs of confusion, disorientation, and varying levels of awareness. This
led to a diagnosis of post-operative delirium (POD). The patient says she feels
"lost" and has trouble remembering events right after the surgery. She also feels
anxious about her mental state and how it might affect her independence.
 Assessment – Since the last assessment, J.S. has shown some improvement in her
orientation, especially during the daytime. However, she still has confusion
episodes, particularly in the evening, which is typical of sundowning. We have
used non-drug interventions, such as re-orientation strategies and a regular
sleep-wake cycle. The patient's family has been involved in offering support and
familiar stimuli to help with her re-orientation.
 OBJECTIVE:
 History:
o She has hypertension that was diagnosed almost 10 years ago
o She also has type 2 Diabetes Mellitus, which she claims was diagnosed 5
years ago
o Osteoarthritis, affecting bilateral knees and hips
 Medications:
o Lisinopril 10 mg daily, PO (for hypertension): This is an ACE inhibitor
that is normally used to manage blood pressure. The drug works by
preventing the conversion of angiotensin I to angiotensin II. It also lowers
the rate of vasoconstriction and aldosterone secretion.
o Metformin 500 mg twice daily, PO (for diabetes management): This drug
is a biguanide. Its primary role in the patient’s care is to reduce the level
of hepatic glucose generation in the body. Also, the drug increases insulin
sensitivity when consumed.
o Acetaminophen 500 mg PRN q4-6h, PO (for osteoarthritis pain): A non-
opioid analgesic used for mild to moderate pain relief.
 Allergies: Penicillin: Causes hives, swelling, and difficulty breathing
(anaphylaxis).
 Labs/imaging/diagnostics:
o CBC: WBC 7.2 x10^9/L, Hgb 13.5 g/dL, Hct 40%, Plts 250 x10^9/L
(within normal limits)
o CMP: Glucose 150 mg/dL, BUN 15 mg/dL, Creatinine 0.8 mg/dL (stable
renal function)
o Urinalysis: Negative for UTI
o CT scan of the head: The results show no acute intracranial findings
 General Appearance: The patient is alert but intermittently disoriented. She
maintains good eye contact during periods of lucidity.
 Vital Signs:
o BP: 112-142/54-78 mmHg (over the past 24 hours)
o HR: 56-78 bpm, regular rhythm
o RR: 16-20 breaths/min, unlabored
o Temperature: The patient’s T-max taken over the past 24 hours ranged
from 98.2°F to 100.4°F; current temp is 98.6°F (37°C).
o Weight: 160 lbs (72.6 kg); weight trend shows an increase of 2 lbs since
admission.
o O2 Saturation: 96-98% on room air; no supplemental oxygen required.
 Skin: No rashes, bruising, or ulcerations noted. The surgical wound site is clean,
dry, and intact.
 HEENT:
o Head: The results show that the patient’s head is normocephalic and
atraumatic.
o Eyes: Her pupils are both equal, round, and responsive to light and
accommodation (PERRLA). Also, she does not show any signs of
conjunctival injection or scleral icterus. The fundoscopic test reveals no
hemorrhage or papilledema. The patient’s extraocular movements (EOM)
 appear normal with full visual fields.
o Ears: The patient does not have discharge. Her tympanic membranes
appear normal and intact without any signs of inflammation. Her acuity is
also normal.
o Nose: There is no discharge or abnormal tenderness observed. The
mucosa looks pink, and there is no turbinate inflammation. There is no
tenderness in the frontal or maxillary sinuses.
o Mouth/Throat: Dentation is fair. No exudate or erythema is observed.
Tonsils appear intact and of normal size. The patient does not show any
signs of tonsillitis.
 Neck: No visible masses. The patient enjoys a full range of motion without pain.
The trachea appears intact at the midline with no deviation.
 Breasts: The skin looks normal with no changes. Symmetry is preserved without
any masses or tenderness observed. Also, she does not show any discharge or
dimpling.
 Heart: The patient has a regular rhythm and heart rate. Also, there is no
abnormal galloping, murmuring, clicks, movements, or rubbing detected in the
chest area.
 Lungs: Chest expansion is symmetrical during breathing. The patient did not
show wheezing or crackles. Her percussion shows resonant sounds.
Diaphragmatic movement is normal.
 Abdomen: Soft and non-tender, with no scars. The patient has normal bowel
movements and sounds. Also, no guarding, masses, or rebound tenderness was
observed. The liver and spleen are not felt. No CVA tenderness.
 Genitourinary: Female: The patient’s external genitalia are intact. Her vaginal
mucosa appears normal without discharge or lesions observed.
 Rectal: The patient shows normal and intact sphincter tone without any
abnormal masses or occult blood observed.
 Musculoskeletal: No weakness or atrophy seen. The range of motion for the
joints appears stable and full. No redness or tenderness observed. The spine
appears straight; gait is steady without instability.
 Vascular: Carotid pulses are 2+ on both sides, without bruits. Popliteal, dorsalis
pedis, radial, femoral, and posterior tibial pulses are 2+ and equal on both sides.
No varicose veins or swelling observed.
 Lymphatic: No cervical, infraclavicular, axillary, supraclavicular, or inguinal
adenopathy detected.
 Neurologic: The patient’s cranial nerves II-XII appear normal and intact.
Sensation and strength are normal in all limbs. The same goes for her reflexes,
which are intact and showing symmetry. Gait is steady; no coordination issues
noted.
 Mental Status: The patient appears. Also, she shows correct orientation to time,
person, and place. The MMSE score is 21/30, indicating mild cognitive
impairment. No signs of confusion or disturbances in the patient’s perception
were observed.

 ASSESSMENT/PLAN:
 Differential Diagnosis:
1. Post-operative delirium (POD): POD is the patient’s main diagnosis. It
shows sudden confusion and changes in thinking abilities (American
Psychiatric Association, 2013).
2. Medication-induced delirium: Check if current medications, especially those
with anticholinergic effects, might contribute to the issue.
3. Infection (UTI, pneumonia): Even if the first tests are negative, continue
monitoring closely.
4. Electrolyte imbalance: Look for and fix any problems with sodium,
potassium, or calcium levels.
5. Hypoglycemia: Even with diabetes under control, low blood sugar can cause
changes in mental status.

 Assessment/Diagnosis
1. Post-operative delirium (ICD-10: F05) is delirium caused by a known
physiological condition, such as the aftereffects of surgery (Codify by AAPC,
n.d.a). This condition likely has multiple causes, including surgical stress,
anesthesia, and existing health issues.
2. Hypertension (ICD-10: I10) refers to essential (primary) high blood pressure
or hypertension that does not have any apparent secondary sources (MD
Clarity, n.d.a). It is managed with Lisinopril, and it is important to monitor
for orthostatic hypotension (Benetos et al., 2019).
3. Type 2 Diabetes Mellitus (ICD-10: E11.9) is an indicator that Type 2
Diabetes is present. However, there are complications observed as a result
(MD Clarity, n.d.b). This condition is managed with Metformin, and it's
essential to monitor glucose levels.
4. Osteoarthritis (ICD-10: M15.9) refers to polyosteoarthritis, unspecified,
which means arthritis affects multiple joints (MD Clarity, n.d.c). Management
includes using Acetaminophen as needed and assessing pain levels.
5. There is a risk of falls due to delirium and possible medication side effects.

 Plan:
 Post-operative delirium:
o Continue non-drug interventions. Provide frequent re-orientation, keep
the environment calm, ensure adequate sleep, and involve family to offer
familiar stimuli (Aldecoa et al., 2017).
o Monitor and manage pain. Use non-opioid pain relievers when possible to
lower the risk of worsening delirium.
o For medication, if agitation continues, the patient may take low-dose
Haloperidol (0.5 mg PO PRN) or Quetiapine (12.5 mg PO PRN). Monitor
for QTc prolongation and movement side effects.
o Conduct daily assessments based on the Confusion Assessment Method
(CAM) to track progress (Inouye et al., 1990).
 Hypertension:
 o Continue Lisinopril 10 mg daily, PO.
o Monitor blood pressure daily and check for orthostatic hypotension
(Alshami et al., 2018).
 Type 2 Diabetes Mellitus:
o Continue Metformin 500 mg twice daily, PO.
o Check glucose levels before meals and at bedtime.
 Osteoarthritis:
o Continue Acetaminophen 500 mg PRN every 4-6 hours, PO.
o Encourage gentle range of motion exercises to keep joint mobility.
 Risk for Falls:
o Implement fall precautions. Use bed alarms, non-slip socks, clear
pathways, and provide help with walking.
o Evaluate the need for a physical therapy consult for mobility and balance
training.

OTHER DOCUMENTATION REQUIRED

 RISK FACTORS
1. Increased Risk of Infection:
o Rationale: The patient's recent abdominal surgery and post-operative
delirium increase her vulnerability to infections, particularly nosocomial
infections (hospital-acquired infections). Surgical sites are susceptible to
infection, and the altered mental status associated with delirium may
impair her ability to recognize and report symptoms of infection promptly.
Additionally, her age and comorbidities, such as diabetes, further
compromise her immune response, making her more susceptible to
infections during hospitalization (Riojas, 2022).
2. Risk of Pressure Ulcers:
 Rationale: Given the patient's limited mobility due to post-operative
recovery and cognitive impairment related to delirium, she is at increased
risk for developing pressure ulcers. Prolonged immobility, combined with
altered skin integrity from potential moisture, friction, and nutritional
deficiencies, can contribute to skin breakdown (Atkinson & Cullum,
2018). Regular skin assessments and repositioning are essential to
mitigate this risk.

CLINICAL PEARL
Post-operative delirium in elderly patients often has multiple causes. These include
surgical stress, anesthesia, medications, and existing medical conditions. A wide-ranging
approach that tackles these factors, along with non-drug treatments, is essential for
effective management and better results. Recognizing and addressing the issue early can
greatly improve outcomes and lower the chance of long-term cognitive decline (Inouye et
al., 2014).
ADDITIONAL COMMENTS/SELF-REFLECTION
Caring for J.S. has shown the challenges of managing post-operative delirium in older
 patients. It is important to create a supportive and calming environment, involve family
in the care plan, and watch carefully for any changes in mental status. Ongoing
assessment and changes to the treatment plan are needed to improve patient outcomes.

References

Aldecoa, C., Bettelli, G., Bilotta, F., Sanders, R. D., Audisio, R., Borozdina, A., ... & European
Delirium Association. (2017). European Society of Anaesthesiology evidence-based and
consensus-based guideline for postoperative delirium. European Journal of
Anaesthesiology, 34(12), 851-881. [Link]

Alshami, A., Romero, C., Avila, A., & Varon, J. (2018). Management of hypertensive crises in
the elderly. Journal of geriatric cardiology: JGC, 15(7), 504. MD Clarity. (n.d.a). ICD
Diagnosis Code I10: What It Is & When to Use. Retrieved August 08, 2025, from
[Link]

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Arlington, VA: American Psychiatric Publishing.
[Link]

Atkinson, R. A., & Cullum, N. A. (2018). Interventions for pressure ulcers: a summary of
evidence for prevention and treatment. Spinal Cord, 56(3), 186-198.
[Link]

Benetos, A., Petrovic, M., & Strandberg, T. (2019). Hypertension management in older and frail
older patients. Circulation research, 124(7), 1045-1060.
[Link]

Codify by AAPC. (n.d.a). ICD-10 Code for Delirium due to known physiological condition -
F05. Retrieved August 08, 2025, from [Link]

Inouye, S. K., van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal, A. P., & Horwitz, R. I. (1990).
Clarifying confusion: The confusion assessment method. A new method for detection of
delirium. Annals of Internal Medicine, 113(12), 941-948. [Link]
4819-113-12-941

Inouye, S. K., Westendorp, R. G., & Saczynski, J. S. (2014). Delirium in elderly people. The
Lancet, 383(9920), 911-922. [Link]

MD Clarity. (n.d.b). ICD Diagnosis Code E11.9: What It Is & When to Use. Retrieved August
08, 2025, from [Link]
MD Clarity. (n.d.c). ICD Diagnosis Code M15.9: What It Is & When to Use. Retrieved August
08, 2025, from [Link]

Riojas, P. S. (2022). Surgical site infection: risk factors. International Surgery Journal, 9(8),
1510-1512. [Link]