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SOAP Format

The document outlines a structured approach for documenting patient assessments using the S.O.A.P. format: Subjective, Objective, Assessment, and Plan. It emphasizes capturing patient experiences, vital signs, clinical impressions, and treatment plans. Specific examples illustrate how to record patient pain levels, diagnostic considerations, and responses to treatments.

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James Robert DeWitt
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35 views1 page

SOAP Format

The document outlines a structured approach for documenting patient assessments using the S.O.A.P. format: Subjective, Objective, Assessment, and Plan. It emphasizes capturing patient experiences, vital signs, clinical impressions, and treatment plans. Specific examples illustrate how to record patient pain levels, diagnostic considerations, and responses to treatments.

Uploaded by

James Robert DeWitt
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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S- Subjective

SAMPLE, OPQRST, temporal patterns – this includes the things experienced by the patient before
or on your arrival, not the effects of treatment
What the patient says or expresses
Has the patient been seen before for this? What was the result?
Include quotes here
• ‘Pt rates pain 10/10, crushing substernal pressure’
• ‘Pt states “feels like an iron pressed into my abd”’

O- Objective/ Observations
Vitals, exam findings, diagnostic results, observations
What you see/measure/smell/hear/feel
This is where your ‘assessment’ goes
• ‘Pt withdraws from abd palpation’ ‘Pt has alcohol-like smell to his breath’

A- Assessment
Clinical impression/ field/ working diagnosis or diagnoses listed from most to least likely
If the patient has received a clinical diagnosis of the condition for which you have been called (via
hospital workup), include that here (ie, transport from hospital to nursing home)
• ‘DDx- possible hepatitis; cholecystitis; gallstones; cirrhosis; kidney stones’

P- Plan
How have you treated?
How do you plan to address the problem further (for clinic/hospital/community care)?
If the patient has a treatment plan from the hospital, what is it (surgery, meds, OT)?
How did the patient respond to treatments?
• ‘Pt received 650 mg acetaminophen IVPB over 15 minutes with reduction in arm pain
from 8/10 to 3/10’
• ‘Pt given 324 mg ASA PO at 11:30
0.4 mg NTG SL at 11:32 with pain reduction from 8/10 to 7/10, no change in 12 lead
0.4 mg NTG SL at 11:35 with pain reduction from 7/10 to 5/10, ST elevation reduced from
2 mm to 1 mm
0.4 mg NTG SL at 11:38 with pain reduction from 5/10 to 0/10, neg ST elevation on 12
lead’

Hint: Leave space, especially in the S and O sections- you will write additional information
throughout the scenario!
Remember, no leading decimals or trailing zeros!

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