scientific-skills/clinical-reports/references/patient_documentation.md
SOAP (Subjective, Objective, Assessment, Plan) is the standard format for progress notes in clinical practice.
When to use SOAP notes:
Benefits:
Definition: Information reported by the patient (symptoms, concerns, history)
Elements to include:
HPI Elements (use OPQRST for pain/symptoms):
Associated symptoms:
Response to treatment:
Example Subjective section:
S: Patient reports persistent cough for 5 days, productive of yellow sputum. Associated
with fever to 101.5°F, measured at home yesterday. Denies shortness of breath, chest
pain, or hemoptysis. Started on azithromycin 2 days ago by urgent care, with minimal
improvement. Reports decreased appetite but able to maintain hydration. Denies recent
travel or sick contacts.
Definition: Measurable, observable clinical data
Elements to include:
Vital Signs:
General Appearance:
Physical Examination by System:
Standard examination systems:
Laboratory and Imaging Results:
Example Objective section:
O: Vitals: T 100.8°F, BP 128/82, HR 92, RR 18, SpO2 96% on room air
General: Alert, mild respiratory distress, appears mildly ill
HEENT: Oropharynx without erythema or exudates, TMs clear bilaterally
Neck: No lymphadenopathy, no JVD
Cardiovascular: Regular rate and rhythm, no murmurs
Pulmonary: Decreased breath sounds right lower lobe, dullness to percussion, egophony
present. No wheezes.
Abdomen: Soft, non-tender, no organomegaly
Extremities: No edema, pulses 2+ bilaterally
Neurological: Alert and oriented x3, no focal deficits
Labs (drawn today):
WBC 14.2 x10³/μL (H) [ref 4.5-11.0]
Hemoglobin 13.5 g/dL
Platelets 245 x10³/μL
CRP 8.5 mg/dL (H) [ref <0.5]
Chest X-ray: Right lower lobe consolidation consistent with pneumonia
Definition: Clinical impression, diagnosis, and evaluation of patient status
Elements to include:
Format:
Example Assessment section:
A:
1. Community-acquired pneumonia (CAP), right lower lobe (J18.1)
- Moderate severity (CURB-65 score 1)
- Appropriate for outpatient management
- Minimal improvement on azithromycin, likely bacterial etiology
2. Dehydration, mild (E86.0)
- Secondary to decreased PO intake
3. Type 2 diabetes mellitus (E11.9)
- Well-controlled, continue home medications
Definition: Diagnostic and therapeutic interventions
Elements to include:
Medication documentation:
Plan organization:
Example Plan section:
P:
1. Community-acquired pneumonia:
Diagnostics: None additional at this time
Therapeutics:
- Discontinue azithromycin
- Start amoxicillin-clavulanate 875/125 mg PO BID x 7 days
- Supportive care: adequate hydration, rest, acetaminophen for fever
Education:
- Explained bacterial pneumonia diagnosis and antibiotic change
- Discussed expected improvement within 48-72 hours
- Return precautions: worsening dyspnea, high fever >103°F, confusion
Follow-up: Phone call in 48 hours to assess response, clinic visit in 1 week
2. Dehydration:
- Encourage PO fluids, goal 2 liters/day
- Sports drinks or electrolyte solutions acceptable
3. Type 2 diabetes:
- Continue metformin 1000 mg PO BID
- Home glucose monitoring
- Follow-up with endocrinology as scheduled
Patient verbalized understanding and agreement with plan.
Documentation standards:
Billing considerations:
Legal considerations:
Definition: Brief statement of why patient is seeking care
Format:
Purpose: Detailed chronological narrative of current problem
Required elements (for billing):
Structure:
Example:
HPI: Mr. Smith is a 65-year-old man with history of CHF (EF 35%) who presents with
3 days of progressive dyspnea on exertion. Patient reports dyspnea now occurs with
walking 10 feet (baseline 1-2 blocks). Associated with orthopnea (now requiring
3 pillows, baseline 1) and lower extremity swelling. Denies chest pain, palpitations,
or syncope. Reports medication compliance but notes running out of furosemide 2 days
ago. Weight increased 8 lbs over past week. Has not been monitoring daily weights
at home. Presented to ED today when dyspnea worsened and developed while at rest.
Include:
Format:
PMH:
1. Heart failure with reduced ejection fraction (2018), EF 35% on echo 6 months ago
2. Coronary artery disease, s/p CABG (2019)
3. Type 2 diabetes mellitus (2010)
4. Hypertension (2005)
5. Chronic kidney disease stage 3 (baseline Cr 1.8 mg/dL)
6. Hyperlipidemia
Include:
Format:
PSH:
1. CABG x4 (2019), complicated by post-op atrial fibrillation
2. Cholecystectomy (2015)
3. Appendectomy (childhood)
Documentation:
Format:
Medications:
1. Furosemide 40 mg PO daily (ran out 2 days ago)
2. Carvedilol 12.5 mg PO BID
3. Lisinopril 20 mg PO daily
4. Spironolactone 25 mg PO daily
5. Metformin 1000 mg PO BID
6. Atorvastatin 40 mg PO daily
7. Aspirin 81 mg PO daily
8. Multivitamin daily
Document:
Format:
Allergies:
1. Penicillin → anaphylaxis (childhood)
2. Shellfish → hives
3. ACE inhibitors → angioedema
Include:
Format:
Family History:
Father: CAD, MI age 58, alive age 85
Mother: Breast cancer, deceased age 72
Brother: Type 2 diabetes
Sister: Healthy
Children: 2 sons, both healthy
Include:
Format:
Social History:
Tobacco: Former smoker, quit 10 years ago (30 pack-year history)
Alcohol: 2-3 beers per week, denies binge drinking
Illicit drugs: Denies
Occupation: Retired electrician
Living situation: Lives at home with wife, 2-story house, bedroom upstairs
Marital status: Married
Exercise: Unable to exercise due to dyspnea
Diet: Low sodium diet (usually adherent)
Functional status: Independent in ADLs at baseline
Purpose: Systematic screening for symptoms by body system
Requirements:
Systems:
Format:
ROS:
Constitutional: Denies fever, chills. Reports fatigue and weight gain (8 lbs).
Cardiovascular: Reports dyspnea, orthopnea, lower extremity edema. Denies chest pain,
palpitations, syncope.
Respiratory: Denies cough, wheezing, hemoptysis.
Gastrointestinal: Denies nausea, vomiting, diarrhea, constipation, abdominal pain.
All other systems reviewed and negative.
General organization:
Vital signs:
Vitals: T 98.2°F, BP 142/88, HR 105, RR 24, SpO2 88% on room air → 95% on 2L NC
Height: 5'10", Weight: 195 lbs (baseline 187 lbs), BMI 28
System examinations:
General: Well-developed, obese man in moderate respiratory distress, sitting upright in bed
HEENT:
Neck: Supple, no lymphadenopathy, JVP elevated to 12 cm, no thyromegaly
Cardiovascular:
Pulmonary:
Abdomen:
Extremities: 3+ pitting edema to mid-calf bilaterally, no cyanosis or clubbing
Skin: Warm and dry, no rashes
Neurological:
Psychiatric: Anxious affect appropriate to illness, normal thought process
Include:
Example:
Laboratory Data:
CBC: WBC 8.5, Hgb 11.2 (L), Hct 34%, Plt 245
BMP: Na 132 (L), K 3.2 (L), Cl 98, CO2 30, BUN 45 (H), Cr 2.1 (H, baseline 1.8), glucose 145
Troponin: <0.04 (normal)
BNP: 1250 pg/mL (H, elevated)
Imaging:
Chest X-ray: Cardiomegaly, bilateral pleural effusions, pulmonary vascular congestion
consistent with volume overload
ECG: Sinus tachycardia at 105 bpm, left ventricular hypertrophy, no acute ST-T changes
Format: Problem-based with numbered problem list
Example:
Assessment and Plan:
65-year-old man with history of CHF (EF 35%) presenting with acute decompensated
heart failure.
1. Acute decompensated heart failure (I50.23)
- NYHA Class IV symptoms
- Volume overload on exam and imaging
- Precipitated by medication non-adherence (ran out of furosemide)
- BNP elevated at 1250
Diagnostics:
- Echocardiogram to assess current EF and valvular function
- Daily weights and strict I/O
Therapeutics:
- Furosemide 40 mg IV BID, goal negative 1-2L daily
- Continue carvedilol, lisinopril, spironolactone
- Oxygen 2L NC, goal SpO2 >92%
- Low sodium diet (<2g/day), fluid restriction 1.5L/day
- Telemetry monitoring
Follow-up: Will reassess after diuresis, goal discharge in 3-5 days
2. Acute kidney injury on CKD stage 3 (N17.9, N18.3)
- Cr 2.1 from baseline 1.8, likely prerenal from poor forward flow
- Monitor daily, expect improvement with diuresis
- Hold nephrotoxic agents
3. Hypokalemia (E87.6)
- K 3.2, likely from prior diuretic use
- Replete K 40 mEq PO x1, then reassess
- Continue spironolactone for K-sparing effect
4. Hyponatremia (E87.1)
- Na 132, likely dilutional from volume overload
- Expect improvement with diuresis
- Fluid restriction as above
5. Type 2 diabetes mellitus (E11.9)
- Well-controlled
- Continue home metformin
- Monitor glucose while hospitalized
6. Coronary artery disease (I25.10)
- Stable, no acute coronary syndrome
- Continue aspirin, statin, beta-blocker
Code status: Full code
Disposition: Admit to telemetry floor
Requirements:
Principal reason for hospitalization
Format: Numbered list, prioritized
Example:
Discharge Diagnoses:
1. Acute decompensated heart failure
2. Acute kidney injury on chronic kidney disease stage 3
3. Hypokalemia
4. Hyponatremia
5. Coronary artery disease
6. Type 2 diabetes mellitus
Content:
Example (brief):
Hospital Course:
Mr. Smith was admitted with acute decompensated heart failure in the setting of
medication non-adherence. He was diuresed with IV furosemide with net negative
5 liters over 3 days, with significant improvement in dyspnea and resolution of
lower extremity edema. Echocardiogram showed persistent reduced EF of 30%, similar
to prior. Kidney function improved to baseline with diuresis. Electrolytes were
repleted and normalized. Patient was transitioned to oral furosemide on hospital
day 3 and remained stable. He was ambulating without dyspnea on room air by
discharge. Comprehensive heart failure education was provided.
Procedures:
1. Echocardiogram transthoracic (hospital day 1)
Format:
Example:
Discharge Medications:
1. Furosemide 60 mg PO daily [INCREASED from 40 mg]
2. Carvedilol 12.5 mg PO BID [UNCHANGED]
3. Lisinopril 20 mg PO daily [UNCHANGED]
4. Spironolactone 25 mg PO daily [UNCHANGED]
5. Metformin 1000 mg PO BID [UNCHANGED]
6. Atorvastatin 40 mg PO daily [UNCHANGED]
7. Aspirin 81 mg PO daily [UNCHANGED]
Discharge Condition:
Hemodynamically stable, ambulatory, no supplemental oxygen requirement, euvolemic
on exam, baseline functional status restored.
Discharge Disposition:
Home with self-care
Include:
Example:
Follow-up:
1. Cardiology appointment with Dr. Jones on [date] at [time]
2. Primary care with Dr. Smith in 1 week
3. Home health for vital sign monitoring and medication reconciliation
4. Repeat BMP in 1 week (arranged, lab slip provided)
Include:
Example:
Patient Instructions:
1. Weigh yourself daily every morning, call doctor if gain >2 lbs in 1 day or >5 lbs
in 1 week
2. Low sodium diet (<2 grams per day)
3. Fluid restriction 2 liters per day
4. Take all medications as prescribed, do not run out of medications
5. Activity: Resume normal activities as tolerated
6. Return to ER or call 911 if: severe shortness of breath, chest pain, severe swelling,
or other concerning symptoms
This reference provides comprehensive standards for patient clinical documentation including SOAP notes, H&P, and discharge summaries. Use these guidelines to ensure complete, accurate, and compliant clinical documentation.