Guides to get you through your clinical rotations year! SOAP is an acronym for Subjective, Objective, Assessment, Plan. Instead of re-writing an entire consult note, you simply being giving a quick overview of a patient’s status on specific issues at a particular period of time.
S) Subjective: Things the patient says:
Include the disposition of the patient “at time of writing”, whether sleeping, in with a family member, eating, restful, anxious.
Include pertinent positives of negatives symptoms, making note of: Chest pain, Nausea/vomiting, Abdominal Pain, Shortness of Breath, Dizziness, etc.
Write down the patient’s voiced concerns.
O) Objective: Things that can be measured: Here include vital signs, physical examination findings, blood work, and any investigations (bloodwork, x-ray, etc.) from that day.
HR: Heart rate, between 60-100 is considered normal in adults
RR: Respiratory rate1 8-20 is the average.
SaO2: Oxygen Saturation.
In a normal healthy person, this is usually 98-100% on room air (sometimes abbreviated RA). If a patient is sicker, like in Chronic Obstructive Pulmonary Disease (COPD), this can be lower, usually 88-92%.
You should specify how the patient is breathing, usually in RA (room air), TM (tracheal mask), or Nasal Prongs (NP)
If the patient is receiving oxygen, note how many litres of oxygen they are receiving, OR how much inspired oxygen. In normal atmospheric air (e.g. room air), it is 20% inspired oxygen. Other times, if they are receiving exogeneous oxygen, they may receive a higher content of oxygen (e.g. 32%).
This isn’t something you usually have to determine yourself, and can be found in the nursing notes.
Greater than 38.5 degrees Celsius is considered “febrile”. Greater than 40.1 degrees Celsius starts causing protein denaturation and therefore possible neurological changes.
AVSS: usually is an abbreviation for “All vital signs stable”, but it is good practice to specify the vital signs in your note.
CVS: Cardiovascular findings
Resp: Respiratory Findings
Abdo: Abdominal Exam
PVS: Peripheral Vascular Exam
Neuro: Neurological exam. It is good to include whether the patient is alert and oriented
Imaging (x-ray results), etc.
A/P) Assessment/ Plan: This section is usually combined, and is issue oriented. So this is similar to the consult note. List most prominent and active issues first, then the less important, stable issues.