PROGRESS NOTE (SOAP Notes) H.A.Soleimani MD Gastroenterologist.

PROGRESS NOTE(SOAP Notes)

H.A.Soleimani MDH.A.Soleimani MD

Gastroenterologist Gastroenterologist

PROGRESS NOTE (SOAP Notes (

The medical student should be the person most intimately aware of the patient's status, it is appropriate that he or she be given the responsibility of writing the note each day.


One of the most important documents in the medical record is the daily progress note


The progress noteThe progress noteReflect whatReflect what transpired transpired during the during the previous 24previous 24 hourshoursUpdates a patient's clinical course each day

Summarizes the ward team's ongoing assessment and plan.


Progressnote Progressnote include a include a directed directed or or focal focal examination, and examination, and plansplans for for further further evaluationevaluation..

Use the SOAP formatUse the SOAP format

Subjective

Objective

Assessment

Plan

S=SubjectiveS=Subjective

O=ObjectiveO=Objective

A=AssessmentA=Assessment

P=PlanP=Plan

Progress note

Uses:

1,Daily evaluation of a hospitalized patient

2,Return visit in outpatient clinic

Progress note

Subjective (Focused history)

1. Information you have learned from the patient or people caring for the patient

SUBJECTIVE SUMMARY

The note begins with a statement of the patient's own (subjective) assessment of his condition.

SUBJECTIVE SUMMARY

The subjective portion should include some of the patient’s or parents' own words.

OBJECTIVE SUMMARY

1 -Vital signs

2-The patient's general appearance

3-Physical exam findings

4- Any diagnostic test results (Laboratory and imaging..)

OBJECTIVE SUMMARY

VITAL SIGNS

Blood Presure

Pulse Rate

Respiration Rate

Temperature

(Weight, Pain, xygen xygen SaturationSaturation? )

OBJECTIVE SUMMARY

The patient's general appearance should be noted after vital signs.

OBJECTIVE SUMMARY

PHYSICAL FINDINGS: An directed physical examination should be recorded with all pertinent areas described.

OBJECTIVE SUMMARY

Laboratory data: Although one will often wish to mention certain laboratory data in the assessment, there is no need to list all of the results.


Because the progress note is focused on "progress,' the assessment and plan section includes only problems that are being addressed during the hospitalization.

ASSESSMENT

AssessmentAssessment::Provide Provide your your working working diagnosisdiagnosis and and mention the mention the statestate of of the the patientpatient

ASSESSMENT

Identify the major or primary assessment supported by the patient database and any other associated assessments.

ASSESSMENT

1.What do you feel is the patient’s differential diagnosis and why?

2.Organized by problem or organ system

ASSESSMENT

Every day problem list with Every day differential diagnosis for each problem

PLAN

A separate plan should be developed for each assessment.

PLAN

Each plan should be divided into 1.Diagnostics(Lab .x.ray..)

2.Therapeutic

3.Patient Education

4.Health Promotion

Strategies

PLANPLAN

For each problem what diagnostic testing will you order?

How will you treat each problem or

diseases?

PLANPLAN

Action planned for each problem

A&P( assessment and plan)


Progress note maybe quite brief. It does not need to be crafted in fall sentences as long as it is easily comprehensible.


It is also important to remember that the progress note, like the oral and written presentations, is part of the student's education and should be reviewed with the intern, resident, or attending.


The date, time, title, are essential UUSE SE BLACK INKBLACK INK

SIGN SIGN AND AND writewrite YOUR NAME YOUR NAME on any chart notes

EXAMPLE OF PROGRESS NOTE

(SOAP Notes)


SUBJECTIVESUBJECTIVESUBJECTIVE

PROGRESS NOTE (SOAP Notes

Mr. Hamedi is an 84 year old man who comes to the hospital 7 day ago for angiography and today he have worsening leg swelling. The swelling started 3 days ago in his ankles and has progressively moved toward his groin.

PROGRESS NOTE (SOAP Notes

He also feels short of breath. For the past two days he can’t walk without resting halfway. He has difficulty breathing when lying in bed.


OBJECTIVEOBJECTIVEOBJECTIVE

PROGRESS NOTE (SOAP Notes)

1. Vital signs: BP 120/72, HR 68,

RR 20, T 36

2. Chest: crackles 1/3 up bilaterally.


Extremities: No erythema or tenderness.

2+ pitting edema bilaterally to his knees.


3.Cardiac: Regular rate and rhythm, normal S1 and S2, S3 is present, No murmur


Abdomen: Normoactive bowel sounds,

soft, non-tender, non-distended, no hepatomegaly or splenomegaly


Labs visit: Sodium 125 (135 -145)

Potassium 3.6 (3.5 – 5.1)

BUN 40 (10 – 20)

Creatinine1.5 (0.6 – 1.3)


ASSESSMENTASSESSMENTASSESSMENT


Shortness of Breath

New dyspnea on exertion

S3 crackles and edema

1.Congestive heart failure or new anginaor new anginaASSESSMENT

Problem


EdemaProblem

ASSESSMENT

1.Congestive heart failure or new anginaor new angina

2.Nephrotic syndrome

3.hypothyroidism


No suggestion of

pure pulmonary disease

No suggestion of Hypertension –Blood presure is well controlled and is probably not contributing to his

presenting complaints.


PLANPLANPLAN

Congestive heart failure or new or new anginaangina

We will order an EKG right now to assess cardiac rhythm and acute injury.

Congestive heart failure or new or new anginaangina

We will also send him for an echocardiogram to measure his cardiac function.

Nephrotic syndrome

We will check a urinalysis to rule out the

proteinuria of nephrotic syndrome

Hypothyroidism

Check a thyroid stimulating hormone level to evaluate his thyroid function.

Hypertension

No changes are needed in his blood pressure medication.

PROGRESS NOTE (SOAP Notes) H.A.Soleimani MD Gastroenterologist.

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