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Jefferson Medical College Alpha Omega Alpha Guide to the Clinical Years
The SOAP Note
The SOAP note will be one of your most important responsibilities as a third or fourth year student. The mnemonic stands for Subjective, Objective, Assessment and Plan. We've also included two sample SOAP notes for your review:
Daily notes can vary from rotation to rotation, but the general principle is the same: to record the progress of your patient. Surgery and OB/GYN notes tend to be shorter than Internal Medicine notes. However, all records should be thorough and complete. This is your opportunity to record any subjective findings such as quality of pain relief, document objective findings such as vital signs and the physical examination, and then to give your assessment of the patient’s problems and to recommend lab tests or therapeutic interventions. This is all included in your SOAP note.
Depending on the clerkship, you may be asked to follow anywhere from two to six patients per day. It is important to be able to budget your time in seeing each patient in the morning and being able to complete an accurate note.
The Subjective aspect of the progress note is a subjective description of the patient's overnight stay (i.e. symptoms not signs). It may be a good idea to include a patient quote, for example “I feel good this morning but it still hurts when I take a deep breath.” Nursing comments can also be included, especially if the patient is unconscious or cannot communicate. Remember to be as inclusive as possible.
The Objective portion of the note includes the vital signs, physical exam, laboratory results, and other study results. Tailor the physical exam for each patient and rotation. Always start with the vitals and don't forget the in’s and out’s for urine, drains, etc. For temperatures, always give the maximum temperature over the past 24 hours (Tmax), as well as the most recent recording (Tcurrent). Note how much of the PRN pain meds are being used, if at all. Some residents will ask you to write the patient’s medication list each day, and others will prefer that you don't bother doing so. However, the most important thing is to know what medications the patient is actually receiving (the patient may refuse some medications), and if there have been any dosage changes.
The Assessment is essentially a one or two line summary of the patient, incorporating hospital day #, reason for admission, antibiotic day #, post-operative day #, and current medical issues or relevant lab/study results. Although the above sample SOAP note lists assessments by organ system separately from the plan below, most students and residents incorporate the assessment and plan into a single organ system based paragraph, described in the next section.
The Plan is the final part of the note and the aspect with which medical students may struggle the most. Don’t worry; this is what you’re here to learn. Divide the list by problem or by system, whatever you choose. Recommend labs or treatments. Think of the patient's needs. Some residents or attendings will ask you to write a separate problem list before writing the assessment and plan. In addition to organ system based issues, fluid/electrolytes/nutrition (F/E/N), prophylaxis, and disposition are important to address in the plan. These management issues are completely foreign to the new third-year student, and are not something you need to think about immediately.
The Maxwell Guide (see the Guide to the Internal Medicine clerkship) is a superb resource for remembering pertinent review-of-systems, physical exam, lab diagrams, etc. during the crunch time of finishing your notes before rounds. First Aid for the Wards includes sample SOAP notes tailored to each core third-year rotation, and can also be quite helpful.
Last revised: 6/08