S.             Patient still c/o productive cough (small amounts brown sputum) with fever + chills.
                 Spiked to 102 overnight.  Patient denies headache, nausea, vomiting, diarrhea

O.
Vitals       T=992   Tmax=1015  @2am                             HR 90, regular    BP120/70                   RR24
                 Weight 65kg
                 I/O  Input – PO, NS @100cc/hr   Output – BR

PE           General:  Pt resting comfortably in bed.  NAD.
                 HEENT:  Head – NC/AT. Eyes – PERRL, EOMI. Oropharynx- ?injection/exudate
                 Neck:  supple, good ROM; ? LAD
                 Chest  Crackles in right base; ? egophany.  Left lung CTA.
                 Cardiac: RRR, Nl S1 S2, ? m/r/g
                 Abdomen: soft, NTND  BS?
                 Extremities: WWP, ? c/c/e, peripheral pulses 2+ throughout
                 Neuro A&O X3
Labs
 

                                                                                                                                                                                                                    Jane Doe, CC3
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
C/O= complains of; NC/AT= normocephalic/atraumatic; PERRL=pupils equally round, reactive to light; EOMI= extraocular muscles intact; NAD= no acute distress; ROM= Range of motion; LAD=lymphadenopathy; CTA=clear to auscultation; RRR=regular rate and rhythm; NTND=nontender, nondistendedWWP=warm, well perfused; c/c/e=clubbing, cyanosis, edema; FEN=fluids, electrolytes, nutrition BR= bathroom privileges.
 

Tips On Medical SOAP Notes

The heading of the progress note should include the date, time, who is writing the note (CC3, CC4, PGY1, Chief Resident etc.), and the service (Red surgery, Gyn, Neurology etc.).  Always list the antibiotics and what day of the antibiotics at the top of the progress note along with other meds and doses.

Subjective information is what the patient tells you.  How are they feeling?  What are their symptoms?  What are they eating (if NPO, note it here)?  Are they sleeping well?  Are they ambulating, urinating, defecating, passing gas?  If they have diarrhea, describe it here (e.g. "green and watery x3 last night").

You have already learned to clarify a chief complaint, which is also subjective, and you should ask the same kinds of questions to clarify the subjective information.  If a patient tells you he is "doing poorly,"  you should not write this in your note (this may be construed as your assessment).  Get a good description of the symptoms, and write:   "Pt. c/o (Patient  complains of) abdominal distention and pain in right shoulder exacerbated by inspiration and change of position/exertion."

Objective information is what you gather from your physical exam and from other tests.  Begin with the vital signs. Also include total fluid input and output over the last shift  (I's & O's) if the patient is NPO or on a diuretic regimen.  You should also record the patient’s weight if daily weights are being recorded.  Then write your physical exam including only pertinent positives and negatives.  What is considered "pertinent" will also change for each rotation, so be prepared for feedback.

After the exam, write the results of laboratory tests which have not yet been entered into the chart.  The shorthand format for writing lab results is as follows:  draw the grids shown below and then fill the lab value in to the spaces- e.g. the Na value should go in the upper left hand corner of the grid below.  This saves you the trouble of writing "Na, K, Cl, BUN," etc many times each day.

There is also a complicated grid some people use for LFTs, but you are better off just writing them out unless your housestaff tell you otherwise.  After the labs, include the results of other studies which have not yet been noted in the chart.  These include EKG, x-rays, CT scans, etc.  If a lab or test has been ordered but the results are not yet back, note that the test is pending.

The assessment is what you think is wrong with the patient.  Your assessment should make it clear that you understand the crucial differential for each problem- but don't include the differential unless your housestaff approves.  This is the most important, and difficult, part of the note, so get as much feedback as possible.  The assessment is also a summary of how the patient is doing and what has changed from the previous day.  For example:  are they defervesing, are they still with symptoms, has their white count improved etc.

The plan is what you are going to do about each problem such as medication, labs to order, tests to obtain, consults that should be called.

Most people put the assessment and plan in one section (A/P).  One way to organize the A/P section is to divide it into systems (FEN, CV, Pulm, ID, Neuro etc) as shown in the example. Another way is to make a problem list for the patient beginning with the most serious problem.  Again, the format you use will change for each rotation.The surgical style SOAP note applies to the general surgery, gynecology, and urology clerkships.  You will not be writing notes in ENT surgery, neurosurgery, or orthopaedic surgery.  The most important feature of the surgical SOAP note is its brevity.  The residents will inform you if your note is not to their liking and you should adjust your style accordingly.