Example of a good SOAP note

[nbd13]

Hey everyone,

Does anyone have an example of a good SOAP note? Or a link to a website with some good examples?

Thanks,

Nick

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[Jolie South]

This varies vastly by the service.

Consider medicine and surgery. Those notes are going to be radically different yet still use the SOAP format.

 

[just one]

http://soaps.sheknows.com/

I use this when I fall behind

 

[OveractiveBrain]

Heres something to keep in mind

SOA: NOBODY GIVES A **** or prove to your resident you looked, checked, and actually did something.

P: What people actually read. What people actually care about. Where you should focus the most time.


S: No Acute Distress. Pruritis overnight that resolved with benadryl
O: VS 16 84 112-155/86-99 98% on RA
RRR
CTAB, Nml WoB
NT ND pos BS
LABS
A: 63 yo M with
(1) Acute Pancreatitis
(2) AKI
(3) Constipation
(4) Hypokalemia
P:
(1) Day 2 of hospitalization shows a ranson's criteria of 2. Continue IVF, NPO bowel rest, and analgesia, monitor for signs of complications
(2) Likely prerenal 2/2 dehydration given BUN/CR >20, give NS 2L, reassess in PM
(2) Lactulose prn
(3) Replete K with po potassium