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How to
write a SOAP Note
Date/Time
Medical
Student Progress Note (MSPN) -- Day # -
| Problem List |
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Medications |
Numbered in order of importance
Each will be addressed
in the H&P |
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Each drug with dosages, route, timing. List antibiotic day
#. |
S:
What the
patient says, in their words
- How was the preceding day/night?
- any complications from procedures/dialysis/physical therapy?
- any adverse reactions to medications?
- how is the current problem? better? worse? changing?
- any chest pain? SOB? N/V/D?
- any new problems? any questions?
For surgery/ob:
- have you urinated? passed gas? had a bowel movement? since surgery
- any pain/bleeding at the incision site?
- are you up and walking around? (to prevent DVT/PE)
- are you breathing deeply/coughing? (to prevent atelectasis)
O: what you find on examination
|
Med/Peds: |
|
Surg/Ob: |
| VITALS |
Pulse, BP, Resp Rate, Temp |
|
VSS, afebrile (Tm) |
| LUNGS |
CTA
B/L
no wheezes/rales/rhonchi
no accessory muscle use |
|
CTA
B/L
no wheezes/rales |
| HEART |
rate X, regular rhythm
+S1S2, -S3S4
-
murmor/gallops/clicks |
|
RRR, +S1/S2 |
| ABDOMEN |
normoactive BS, soft, nontender, nondistended,
-rebound/guarding
- organomegaly
- palpable/pulsatile
masses |
|
NA
BS, soft
NT/ND |
| EXTREM |
+2
pulses bilat, nontender
no cyanosis, clubbing, or edema
good
skin turgor
capillary refill < 2 seconds |
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C/C/E. NT,
2+ pulses bilat |
| WOUND |
clean, dry, intact, - erythema, edema, bleeding, or discharge
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C/D/I - d/c |
- In general, list
positive findings before negative findings.
- In any specialty
expand on the system that is the problem -- do a complete exam each
morning targeting the areas of interest. You should listen to everyone's
heart and lungs, and feel everyone's belly (even in surgery).
A/P:
By problem,
list assessment (better/worse/different), diagnostics to be ordered,
therapeutics to continue/change, and any issues to follow
up.
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