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SOAP Notes Writing

Muhammad F. Zaitoun, PharmD (MSc)

After this lecture you should Know

Importance of the SOAP Notes
How to Write SOAP notes?

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S = Subjective
Descriptive notes about the patient condition obtained from

the patient/relatives/caregiver words

What happened ? How it happened ? Where it happened (e.g. surface, weather conditions, etc.) ?

S = Subjective
When it happened ?
How the patient feels (his Complains) Medical/surgical history (According to the patient /relatives /caregiver ) Response to previous treatment intervention

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S = Subjective (Things to Consider)

Organization; concise Verbs: states, feels, describes, denies, indicates, c/o Quoting the patient words
To illustrate confusion or memory loss To illustrate denial To describe pain

S = Subjective (example)
Mr. Otaibi is a 70year old man who comes to the hospital 5 day
ago for angiography and today he have worsening leg swelling. The swelling started 4 days ago in his ankles and has progressively moved toward his groin. Patient feels short of breath. For the past two days he cant walk

without resting halfway. He has difficulty breathing when lying in

bed.

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O=Objective
1 -Vital signs (Blood Presure, Pulse Rate, Respiration Rate ,Temperature)

2-The patient's general appearance

3-Physical exam findings (Systems review) 4- Any diagnostic test results (Laboratory and imaging..) 5- Medical history when taken from the medical record

O=Objective (example)
1. Vital signs: BP 120/72, HR 68, RR 20, T 36
2. Chest: crackles 3. Extremities: No erythema or tenderness. 2+ pitting edema bilaterally to his knees. 4. Cardiac: Regular rate and rhythm, normal S1 and S2, S3 is present, No murmur

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O=Objective (example)
5. Abdomen: Normoactive bowel sounds, soft, non-tender, nondistended, no hepatomegaly or splenomegaly 6. Labs visit: Sodium 125 (135 -145) Potassium 3.6 (3.5 5.1) BUN 40 (10 20) Creatinine1.5 (0.6 1.3)

A= Assessment
Provide your professional opinion
Etiology
Is it drug induced Risk factors

Is therapy indicated
Mild, moderate, and severe problem

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A= Assessment
Current therapy and/or new therapy
Systemically evaluate current therapy Is it the best option, dose, dosage form, duration, required or not, is the patient responding, ADR, compliance of patient

P=Plan
Where do you want to go and how are you going to get there? Recommend drug treatment; further tests (TDM) Drugs to be avoided Goals:
Long-term Short-term

Discharge plans/patient education

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