The Focused Interview, SOAP Notes and Progress Notes

  1. The SOAP note is a focused note that reflects the current problem (chief complaint) that the patient is seeking help for at this visit
  2. It is rarely used to document the patient’s complete history as a new patient, it is used in ambulatory, ER and follow-up settings
  3. Only the patient complaint at this visit is investigated and followed in the HPI
  4. The HPI is much shorter- still fundamental OPQRST
  5. The ROS is no longer a complete and separate section, only pertinent ROS will be included in the HPI- remember to include all pertinent positive and negatives
  6. You will augment that HPI with addition of medical knowledge to ask questions about:

  1. Risk factors
  2. Relation to certain factors
  3. Psychosocial issues and behaviors

  1. A full physical examination is not necessary- focused for the CC, PMHx, age
  2. The progress note is use to document and record patient’s progress, many times as an in-patient admitted to the floor. The patient is “rounded-on” daily, to see how they are responding to treatment and to determine whether new problems have arisen
  3. Is patient getting adequate pain relief from analgesia? Can activity be advanced?
  4. Has bowel activity returned? Can diet be advanced?
  5. Can any sutures, staples, drains be removed?
  6. Complaints or new problems? Post-operative complications (5 Ws)?
  7. Wind (Atelectasis), water (UTI), walking (DVT), wound (wound infection), wonder drugs (Abx caused another infection somewhere else
  8. Legal Consequences
  9. Permanent part of the patients record, use black ink
  10. Subject to legal scrutiny- must be legible, understandable and complete
  11. The SOAP Note
  12. Date, time, service (geriatrics, orthopedics, etc)
  13. Identifying date, source of information, reliability
  14. Chief complaint:1 symptom x duration
  15. (S) Subjective: How does the patient feel at present? Any complaints?
  16. Are basic bodily and mental functions normal, age appropriate?
  17. Past medical history
  18. Hospitalizationsdate, hospital, diagnosis/procedure, length of stay, complications
  19. Surgeries
  20. MedicationsName, dose, route, frequency, indication
  21. AllergiesDrug, food, environment- if positive, reaction
  22. Social and family historyDrugs, alcohol, smoking, and sexual history
  23. (O) ObjectiveVital signs
  24. General survey and physical exam
  25. (A) AssessmentEvaluation of data and conclusions that can be drawn
  26. Diagnosis and differentials- R/O only if you plan to do something******************
  27. Often listed and treated in order of priority- most serious first
  28. (P) PlanOrder any labs, diagnostic test or medications
  29. Schedule follow-up appointment
  30. Chronic diseases and healthcare maintenance- change or addition

Signature, PA-S with preceptor co-signature

  1. The Progress Note
  2. Date, time, service (geriatrics, orthopedics, etc.)
  3. Identifying date, source of information
  4. Post operative day (#)- S/P procedure- may replace CC
  5. (S) Subjective:How does the patient feel at present? Any complaints?
  6. Resolution or worsening of previous symptoms?***********************
  7. Symptoms of post-operative/procedural complications?
  8. Past Medical History
  9. MedicationsName, Dose, Route, Frequency, indication
  10. AllergiesDrug, food, environment- if positive, reaction
  11. (O) Objective:Vital signs
  12. General survey and physical exam
  13. Results of blood work, imaging studies
  14. (A) AssessmentEvaluation of date and conclusions that can be drawn
  15. Diagnosis and differentials- R/O only if you plan to do something
  16. (P) PlanOrder any labs, diagnostic tests or medications
  17. Chronic diseases and healthcare maintenance- change or addition

Signature, PA-S with preceptor co-signature