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 S=Subjective P=Plan O=Objective A=Assessment

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

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?

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

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

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. 1

EXAMPLE OF PROGRESS NOTE OBJECTIVE

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

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

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

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

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) OBJECTIVE

EXAMPLE OF PROGRESS NOTE ASSESSMENT

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

PROGRESS NOTE (SOAP Notes) Problem Edema ASSESSMENT 1.Congestive heart failure or new angina ASSESSMENT 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

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

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

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

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

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