2. PROGRESS NOTE (SOAP Notes)
H.A.Soleimani MD
Gastroenterologist

3. 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.

4. PROGRESS NOTE (SOAP Notes (
One of the most important documents in the medical record is the daily progress note

5. 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.

6. PROGRESS NOTE (SOAP Notes (
Progressnote include a directed or focal examination, and plans for further evaluation.

7. Use the SOAP format S=Subjective P=Plan O=Objective A=Assessment

8. Progress note Uses: 1,Daily evaluation of a hospitalized patient
2,Return visit in outpatient clinic

9. Progress note Subjective (Focused history)
1. Information you have learned from the patient or people caring for the patient

10. SUBJECTIVE SUMMARY
The note begins with a statement of the patient's own (subjective) assessment of his condition.

11. SUBJECTIVE SUMMARY
The subjective portion should include some of the patient’s or parents' own words.

12. OBJECTIVE SUMMARY 1 -Vital signs 2-The patient's general appearance
3-Physical exam findings
4- Any diagnostic test results (Laboratory and imaging..)

13. OBJECTIVE SUMMARY VITAL SIGNS Blood Presure Pulse Rate
Respiration Rate
Temperature
(Weight, Pain, xygen Saturation? )

14. OBJECTIVE SUMMARY
The patient's general appearance should be noted after vital signs.

15. OBJECTIVE SUMMARY
PHYSICAL FINDINGS: An directed physical examination should be recorded with all pertinent areas described.

16. 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.

17. 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.

18. ASSESSMENT
Assessment:Provide your working diagnosis and mention the state of the patient

19. ASSESSMENT
Identify the major or primary assessment supported by the patient database and any other associated assessments.

20. ASSESSMENT
1.What do you feel is the patient’s differential diagnosis and why?
2.Organized by problem or organ system

21. ASSESSMENT
Every day problem list with Every day differential diagnosis for each problem

22. PLAN
A separate plan should be developed for each assessment.

23. PLAN Each plan should be divided into 1.Diagnostics(Lab .x.ray..)
2.Therapeutic
3.Patient Education
4.Health Promotion
Strategies

24. How will you treat each problem or diseases?
PLAN
For each problem what diagnostic testing will you order?
How will you treat each problem or diseases?

25. PLAN
Action planned for each problem
A&P( assessment and plan) 1

26. 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.

27. 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.

28. PROGRESS NOTE (SOAP Notes (
The date, time, title, are essential
USE BLACK INK
SIGN AND write YOUR NAME on any chart notes

29. EXAMPLE OF PROGRESS NOTE
(SOAP Notes)

30. EXAMPLE OF PROGRESS NOTE
SUBJECTIVE

31. 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.

32. 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. 1

33. EXAMPLE OF PROGRESS NOTE
OBJECTIVE

34. PROGRESS NOTE (SOAP Notes)
1. Vital signs: BP 120/72, HR 68,
RR 20, T 36
2. Chest: crackles 1/3 up bilaterally.
OBJECTIVE

35. PROGRESS NOTE (SOAP Notes)
Extremities: No erythema or tenderness.
2+ pitting edema bilaterally to his knees.
OBJECTIVE

36. PROGRESS NOTE (SOAP Notes)
3.Cardiac: Regular rate and rhythm, normal S1 and S2, S3 is present, No murmur
OBJECTIVE

37. PROGRESS NOTE (SOAP Notes)
Abdomen: Normoactive bowel sounds,
soft, non-tender,
non-distended,
no hepatomegaly
or splenomegaly
OBJECTIVE

38. PROGRESS NOTE (SOAP Notes)
Labs visit:
Sodium 125 ( )
Potassium 3.6 (3.5 – 5.1)
BUN 40 (10 – 20)
Creatinine1.5 (0.6 – 1.3)
OBJECTIVE

39. EXAMPLE OF PROGRESS NOTE
ASSESSMENT

40. PROGRESS NOTE (SOAP Notes)
Problem
Shortness of Breath
New dyspnea on exertion
S3 crackles and edema
ASSESSMENT
ASSESSMENT
1.Congestive heart failure or new angina

41. PROGRESS NOTE (SOAP Notes)
Problem
Edema
ASSESSMENT
1.Congestive heart failure or new angina
ASSESSMENT
2.Nephrotic syndrome
3.hypothyroidism

42. 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.

43. EXAMPLE OF PROGRESS NOTE
PLAN
PLAN

44. Congestive heart failure or new angina
We will order an EKG right now to assess
cardiac rhythm and acute injury.
PL[N

45. Congestive heart failure or new angina
We will also send him for an echocardiogram to measure his cardiac function.
PL[N

46. Nephrotic syndrome We will check a urinalysis to rule out the
proteinuria of nephrotic syndrome
PL[N

47. Hypothyroidism
Check a thyroid stimulating hormone level to evaluate his thyroid function.
PL[N

48. Hypertension
No changes are needed in his blood pressure medication. 1