Transcript Document

PROGRESS NOTE
(SOAP Notes)
H.A.Soleimani MD
Gastroenterologist
PROGRESS NOTE (SOAP Notes(
The medical student
should be the person
most intimately aware
of the patient's status,
it is appropriate that
he or she be given
the responsibility of
writing the note each
day.
PROGRESS NOTE (SOAP Notes(
One of the most
important
documents in the
medical record is
the daily progress
note
PROGRESS NOTE (SOAP Notes(
The progress note
Reflect what
transpired during the
previous 24 hours
Updates a patient's
clinical course each day
Summarizes the ward
team's ongoing
assessment and plan.
PROGRESS NOTE (SOAP Notes(
Progressnote
include a directed
or focal
examination, and
plans for further
evaluation.
Use the SOAP format
Subjective
Objective
Assessment
Plan
S=Subjective
O=Objective
A=Assessment
P=Plan
Progress note
Uses:
1,Daily evaluation of
a hospitalized
patient
2,Return visit in
outpatient clinic
Progress note
Subjective (Focused
history)
1. Information you
have learned from the
patient or people
caring for the patient
SUBJECTIVE SUMMARY
The note begins with
a statement of the
patient's own
(subjective)
assessment of his
condition.
SUBJECTIVE SUMMARY
The subjective
portion should
include some of
the patient’s or
parents' own
words.
OBJECTIVE SUMMARY
1 -Vital signs
2-The patient's
general appearance
3-Physical exam
findings
4- Any diagnostic test
results (Laboratory
and imaging..)
OBJECTIVE SUMMARY
VITAL SIGNS
Blood Presure
Pulse Rate
Respiration Rate
Temperature
(Weight, Pain, xygen
Saturation? )
OBJECTIVE SUMMARY
The patient's
general
appearance
should be noted
after vital signs.
OBJECTIVE SUMMARY
PHYSICAL FINDINGS: An directed physical
examination should be recorded with all
pertinent areas described.
OBJECTIVE SUMMARY
Laboratory data:
Although one will
often wish to mention
certain laboratory
data in the
assessment, there is
no need to list all of
the results.
PROGRESS NOTE (SOAP Notes(
Because the progress
note is focused on
"progress,' the
assessment and plan
section includes only
problems that are
being addressed
during the
hospitalization.
ASSESSMENT
Assessment:Provide
your working
diagnosis and
mention the state of
the patient
ASSESSMENT
Identify the major or primary assessment
supported by the patient database and any
other associated assessments.
ASSESSMENT
1.What do you feel is
the patient’s
differential diagnosis
and why?
2.Organized by
problem or organ
system
ASSESSMENT
Every day problem
list with Every day
differential
diagnosis for each
problem
PLAN
A separate plan
should be
developed for
each
assessment.
PLAN
Each plan should be
divided into
1.Diagnostics(Lab .x.ray..)
2.Therapeutic
3.Patient Education
4.Health Promotion
Strategies
PLAN
For each problem
what diagnostic
testing will you
order?
How will you treat
each problem or
diseases?
PLAN
Action planned
for each problem
A&P( assessment
and plan)
PROGRESS NOTE (SOAP Notes(
Progress note
maybe quite brief.
It does not need to
be crafted in fall
sentences as long
as it is easily
comprehensible.
PROGRESS NOTE (SOAP Notes(
It is also important to
remember that the
progress note, like the
oral and written
presentations, is part
of the student's
education and should
be reviewed with the
intern, resident, or
attending.
PROGRESS NOTE (SOAP Notes(
The date, time,
title, are
essential
USE BLACK INK
SIGN AND write
YOUR NAME on
any chart notes
EXAMPLE OF PROGRESS
NOTE
(SOAP Notes)
EXAMPLE OF PROGRESS
NOTE
SUBJECTIVE
SUBJECTIVE
SUBJECTIVE
PROGRESS NOTE (SOAP Notes
Mr. Hamedi is an 84 year
old man who comes to
the hospital 7 day ago for
angiography and today
he have worsening leg
swelling. The swelling
started 3 days ago in his
ankles and has
progressively moved
toward his groin.
PROGRESS NOTE (SOAP Notes
He also feels short
of breath. For the
past two days he
can’t walk without
resting halfway. He
has difficulty
breathing when
lying in bed.
EXAMPLE OF PROGRESS
NOTE
OBJECTIVE
OBJECTIVE
OBJECTIVE
PROGRESS NOTE (SOAP Notes)
1. Vital signs: BP
120/72, HR 68,
RR 20, T 36
2. Chest: crackles
1/3 up bilaterally.
PROGRESS NOTE (SOAP Notes)
Extremities: No
erythema or
tenderness.
2+ pitting edema
bilaterally to his
knees.
PROGRESS NOTE (SOAP Notes)
3.Cardiac: Regular
rate and rhythm,
normal S1 and S2,
S3 is present, No
murmur
PROGRESS NOTE (SOAP Notes)
Abdomen:
Normoactive bowel
sounds,
soft, non-tender,
non-distended,
no hepatomegaly
or splenomegaly
PROGRESS NOTE (SOAP Notes)
Labs visit:
Sodium 125 (135 -145)
Potassium 3.6 (3.5 – 5.1)
BUN 40 (10 – 20)
Creatinine1.5 (0.6 – 1.3)
EXAMPLE OF PROGRESS
NOTE
ASSESSMENT
ASSESSMENT
ASSESSMENT
PROGRESS NOTE (SOAP Notes)
Problem
Shortness of Breath
New dyspnea on exertion
S3 crackles and edema
ASSESSMENT
1.Congestive heart failure or new angina
PROGRESS NOTE (SOAP Notes)
Problem
Edema
ASSESSMENT
1.Congestive heart failure or new angina
2.Nephrotic syndrome
3.hypothyroidism
PROGRESS NOTE (SOAP Notes)
No suggestion of
pure pulmonary disease
No suggestion of Hypertension –Blood presure is well
controlled and is probably not contributing to his
presenting complaints.
EXAMPLE OF PROGRESS
NOTE
PLAN
PLAN
PLAN
Congestive heart failure or new
angina
We will order an
EKG right now to
assess
cardiac rhythm
and acute injury.
Congestive heart failure or new
angina
We will also
send him for an
echocardiogram
to measure his
cardiac function.
Nephrotic syndrome
We will check a
urinalysis to rule
out the
proteinuria of
nephrotic
syndrome
Hypothyroidism
Check a thyroid
stimulating
hormone level to
evaluate his
thyroid function.
Hypertension
No changes are
needed in his
blood pressure
medication.