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Documenting a patient assessment in the notes is something all medical students need to practice. This guide discusses the SOAPframework (Subjective, Objective, Assessment, Plan), which should help you structure your documentation in a clear and consistent manner. You might also find our other documentation guides helpful.
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.
As part of your assessment, you may ask:
“How are you today?”
“How have you been since the last time I reviewed you?”
“Have you currently got any troublesome symptoms?”
“How is your nausea?”
If the patient mentions multiplesymptoms you should explore each of them, having the patient describe them in their ownwords.
You should document the patient’sresponsesaccurately and use quotationmarks if you are directlyquoting something the patient has said.
The objective section needs to include your objective observations, which are things you can measure, see, hear, feel or smell.
Document the patient’sappearance (e.g. “The patient appeared to be very pale and in significant discomfort.”).
Document the patient’s vitalsigns:
SpO2 (also document supplemental oxygen if relevant)
Temperature (including any recent fevers)
An assessment of the patient’s fluidintake and output including:
Drain output/stoma output
Clinical examination findings
Some examples of clinical examination findings may include:
“Widespread expiratory wheeze on auscultation of the chest.”
The assessment section is where you document 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 salientpoints:
“Productive cough (green sputum)”
“Increasing shortness of breath”
“Tachypnea (respiratory rate 22) and hypoxia (SpO2 87% on air)”
“Right basal crackles on auscultation”
“Raised white cell count (15) and CRP (80)”
“Chest X-ray revealed increased opacity in the right lower zone, consistent with consolidation”
Document your impression of the diagnosis (or differential diagnosis):
“Impression: community-acquired pneumonia”
If the diagnosis is alreadyknown and the findings of your assessment remain in keeping with that diagnosis, you can comment on whether the patient is clinicallyimproving 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”
“CRP decreasing (20), white cell count decreasing (11)”