A SOAP Note, aka Progress Note is the daily record of a patient’s time in the hospital. SOAP is a mnemonic to remember the different components of this note. It stands for Subjective, Objective, Assessment, and Plan.
The Subjective section is for everything the patient tells you, the Objective section is for documenting your findings and data, the Assessment section is for a list of the patient’s issues being addressed, and the Plan section is for what you are doing about the items in the assessment. Many times the assessment and plan sections are combined.
SOAP notes are written daily starting on hospital day 2, since on the first day a History and Physical will be completed. A sample template is found below.
Important things to remember:
- The date, time, and signature should always be included.
- A medication list fits very well in the margin. Be sure to include IV fluids, and for antibiotics, how many days the patient has been on each one.
- Put what service you are on and what attending you are following at the top.
- Labs can be written in the shorthand format shown in the sample note.
- Be sure to include Vital Signs, Is and Os, any new radiological data, EKG and telemetry strips.
For more assessment/plan items you can always include DVT and GI prophylaxis (such as SCDs or acid suppression drugs), Disposition (when you think the patient will be discharged), and Code Status (such as Full, DNR, etc.).