Documenting your assessments of patients in the notes is something all medical students need to practice as you’ll be doing this on a daily basis once you start work as a doctor. This guide discusses the SOAP (Subjective/Objective/Assessment/Plan) framework which should help you structure your documentation in a clear and consistent manner. To learn more about documenting in a patient’s notes check out our documentation section here.
The subjective section of your documentation should include how the patient is currently feeling and how they’ve been since the last review in their own words.
So as part of your assessment you may ask:
- “How are you today?”
- “How have you been since the last time I saw you?”
- “Have you currently got any troublesome symptoms?”
- “How has the nausea been?” (or any other relevant symptom)
If the patient mentions multiple symptoms you should explore each of them, having the patient describe them in their own words.
You should document the patient’s responses accurately and use quotation marks if you are directly quoting something the patient has said.
This section needs to include your objective observations, which are things you can measure, see, hear, feel or smell.
Patient’s appearance (e.g. “Patient appears very pale and in discomfort“)
Basic observations (vital signs):
- Blood pressure
- Pulse rate
- Respiratory rate
- Oxygen saturations (including the amount of oxygen the patient is receiving if relevant)
- Temperature (including any recent fevers)
Fluid balance (fluids going in and coming out):
- Oral fluids
- Nasogastric fluids/feed
- Intravenous fluids
- Urine output
- Drain output / stoma output
Clinical examination findings:
- “Widespread expiratory wheeze on auscultation of the chest”
- “Abdomen soft and non-tender”
- “Pulse irregular”
- “No cranial nerve deficits”
Other investigation results:
- Recent lab results (e.g. bloods/microbiology)
- Imaging results (e.g. chest x-ray/CT abdomen)
The assessment section is where you write your thoughts on the salient issues and the diagnosis (or differential diagnosis), which will be based on the information collected in the previous two sections.
Summarise the salient points:
- Productive cough (green sputum)
- Increasing shortness of breath
- Tachypnea (respiratory rate 22) and hypoxia (O2 saturations 87% on air)
- Right basal crackles on auscultation
- Bloods – Raised white cell count (15) / Raised CRP (80)
- Chest x-ray – increased opacity in the right lower zone in keeping with consolidation
Document your impression of the diagnosis (or differential diagnosis):
- Impression – Community acquired pneumonia
If the diagnosis is already known and the findings of your assessment remain in keeping with that diagnosis, you can comment on whether the patient is clinically improving or deteriorating:
- On day 3 of treatment for community acquired pneumonia
- Reduced shortness of breath and improved cough
- Oxygen saturations 98% on air / Respiratory rate 15
- Bloods – CRP decreasing (20) / White cell count decreasing (11)
Impression – Resolving community acquired pneumonia
The final section is the plan, which is where you document how you are going to address or further investigate any issues raised during the review.
Things to consider including in your plan:
- Further investigations – laboratory tests/imaging
- Treatments – medications/IV fluids/oxygen/nutrition
- Referrals to various specialties
- Review date/time – “I will review at 4pm this afternoon”
- Frequency of observations/monitoring of fluid balance
- Planned discharge date if relevant