2 Objectives After this presentation, you will be able to: State the descriptive words for the acronym SOAPGive a brief description of the meaning for each word in the acronym SOAPWrite a progress SOAP progress note from a case study
3 What is a SOAP Note? S = subjective O = objective A = assessment Summary report of client’s/patent’s conditionWritten in client’s/patient's chartAcronym forS = subjectiveO = objectiveA = assessmentP = plan
4 Pros and Cons of SOAP Charting Common use by nutrition care professionals and other medical disciplinesTaught in most dietetics education programsEasy to learn and utilizeCONSCan encourage lengthy chart notesSome physicians are less likely to respond to this format than othersCan downplay continued reevaluation of client’s progressEmphasizes legitimacy of objective over subjective data
5 S: SubjectiveInformation provided/spoken by patient, family, or other person.Pertinent socioeconomic, cultural infoLevel of physical activitySignificant nutritional history: usual eating pattern, cooking, dining outWork schedule
6 Factual and reproducible observations. O: ObjectiveFactual and reproducible observations.DiagnosisHeight, age, weight—and weight gain/loss patternsLab dataClinical data (nausea, diarrhea)Diet orderMedicationsEstimation of nutritional needs
7 A: AssessmentSummary of dietitian's professional nutrition diagnosis or clinical thoughts.Interpretation of patient’s status based on subjective and objective infoEvaluation of nutritional historyAssessment of laboratory data and medicationsAssessment of diet orderAssessment of patient’s comprehension and motivation
8 P: PlanDescribes the scope of Treatment and contains the action plan and prognosis.Diagnostic studies neededFurther lab work or lab data neededMedical nutrition therapy goalsEducation nutrition plansRecommendations for nutritional careDate for any follow-up
9 Sample SOAP NoteSubjective S: works second shift, eats two meals a day, before/after shift; usually eats in fast food restaurants (fried foods, burgers, ice cream) for lunch and dinner. Does not add salt to foods. Takes blood pressure 2x/day. Activity: Plays volley ball on weekends
10 Sample SOAP NoteObjective O: 34 y.o. female; last menstrual period = 01/05/2006; iron level= 12.3; history of hypertension x 2 years; blood pressure = 130/85 for last four readings; height = 5ft. 3in; weight: 205 lb; BMI=36.
11 Sample SOAP Note Assessment A: obese; hemoglobin level normal; excessive sodium intake (NI ) related to frequent use of fast food meals as evidenced by diet history. Blood pressure high/normal. Low physical activity.
12 Sample SOAP NotePlan P: Reviewed DASH diet. Identified foods to pack from home to eat during lunch/dinner. Discussed non-food rewards to purchase with money saved from not eating out when weight and B/P goals are reached. Encouraged more activity to facilitate weight loss. Next appointment = 30 days from today.
13 Conclusion Not all the parts are used at every visit Complete sentences are not necessarySignature goes at end of last lineNever leave a blank line between entriesNever leave a half filled line. Draw a line to fill the line.
14 Lecture QuizWhat does the acronym SOAP stand for and give a brief description of the meaning for each word.What medical professionals usually use SOAP notes?Name one advantage and one disadvantage to using SOAP progress notes.
15 Lecture QuizWrite a progress SOAP progress note using the following case study:Your second appointment for the day is with a 25 year old Chinese male. He states he was told by his doctor that his cholesterol is high and he should to “eat better” but he is confused as to how to do that. He hands you a paper with the following labs on it: height = 67”; weight = 200#; blood pressure = 120/80; total cholesterol = 150 and LDL levels= 160.