Tips On Surgical SOAP Notes

Here is what one should look liike:

Sample Surgery SOAP Note
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4/8/99                                                                         CC3 Urology Progress Note                                                              Cipro 400mg IV BID day #2
6 AM                                                                                          (POD #2)
S        Patient c/o headache. Pain well controlled with Tylenol #3. BM+, Flatus+, Ambulation+
O
          Vitals:T=986  Tmax=1008 @10pm last night  HR 80  BP 120/80 RR 12
           I/O:   Input - LR @ 125 cc/hr, 800cc over 8hr shift
          Output - 1000cc blood tinged urine over 8 hour shift
          10 cc serosanguinous fluid over 8 hour shift via JP drain
          Neuro:AAOx3
          Cardiac: RRR
          Chest: CTA  B
          Abdomen: soft NTND; wound without erythema or exudate, Bowel sounds+
          Extremities No c/c/e; no calf tenderness
A/P   68 y/o male stable POD #2 s/p radical prostatectomy 2 to prostate  adenocarcinoma.
         1. Continue to ambulate
         2. Advance to clears as tolerated
         3. Decrease IVF
         4. Continue Tylenol #3 for pain.
         5. Check AM labs
 

                                                                                                                                                                                                               Jane Doe, CC3
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POD=Post Operative Day; BM=Bowel Movement; LR=Lactated Ringers; JP=Jackson-Pratt drain;
 

The Surgical SOAP Note:

A surgical SOAP note must list the post operative day (POD) if the patient had had an operation.

As stated for medical SOAP notes, the subjective section is where you list the complaints of the patient and overnight events (i.e. a fever spike).  In surgery, be sure to comment on things like vomiting, diarrhea, flatus, and bowel movements.  You can ask the nurse in the AM how the patient was overnight.  The night intern will also be reporting to your intern before rounds so you can also ask them what happened if anything.

As in all SOAP notes, the objective section includes vital signs, intake and output, the physical exam, and labs/studies.  Some important points on this section for surgery:

  1. Note the time that the maximum temperature occurred.
  2. Always specify over how many hours the intake and output were collected.
  3. It is helpful to write the rate of IVF and any other lines such as TPN for intake.You can also record PO intake.
  4. The urine output is very important.  This can be measured in a Foley catheter bagor measured in a bedpan-like contraption that fits over the toilet.  If the patient isnot ordered for strict Is and Os then it is more difficult to determine the exact numbers.  If this is the case, and there is no Foley in place to measure output yourself, you can write the number of voids per day or “bathroom privileges”.
  5. Each drain should be recorded separately and again specify over how many hours.Describe the character of the fluid draining.
  6. The physical exam consists of heart, lungs, abdomen, and extremities.
  7. The wound exam in surgery is important.  Do not change a dressing without asking your resident.  If a dressing is in place, you can write dressing c/d/i which stands for clean, dry, intact.  If a dressing is soaked with drainage, note the type of drainage.  If no dressing is needed or you are changing it, inspect the incision site for erythema and exudate, a.k.a. signs of infection.  Record in your note how the wound appears.
  8. On the Gyn service, after a vaginal hysterectomy or other procedure, note if there is per vaginal bleeding (PVB) as part of your exam.


In surgery, the assessment should include some type of statement regarding the progress of the patient.  For example, “stable” or “doing well”.  Some residents like you to state the patients age, sex,  and type of operation.  Others may prefer you to just write “Stable POD#4”.

The post-op plan will differ from day to day depending on the particular procedure and attending.  You will learn how to devise a plan from your residents i.e. when to advance diet, when to pull drains, when to remove staples etc.