Case presentation and SOAP Notes

Case Presentation and SOAP Notes

Careful and edited production of the essential clinical information.

Builds an argument for diagnosis.

​Oral case Presentation

Contains all medical information

​Everything is described in detail.

Patient’s history, complete physical exam, allergies, medications, family history, social history, and review of systems

​Admission H&P

The Admission H&P Versus the Oral Case Presentation

SOAPS METHOD FOR OC

• Story: The OCP describes key clinical facts.

• Organization: The facts are where the listener expects.

• Argument: The OCP makes the case for assessment
  and plan.

• Pertinence: The OCP includes only information relevant to the assessment and plan.

• Speech: The OCP is articulate.
  

​PMH: Past Medical History

PSH: Past Surgical History

FH: Family History

SH: Social History

ROS: Review of Systems

Definition & Purpose of SOAP note

The SOAP note format is used to facilitate effective communication among the care team by providing assessment findings, identifying problem(s), and developing action plan(s).

Purpose

An organized method of documentation used by providers to describe events involving the participant.

​Definition

Subjective Findings

• Describe how the participant feels.

  Example: Jack reports he is “feeling well and has no concerns.”

• Document what the participant says about his/her current living situation.

  Example: Susan reports she is “happy, healthy and enjoying her new apartment.”

• Record participant’s exact words to describe his/her health.

  Example: John reports he has a “dull headache” and it has lasted over a week.

• Document any mention of changes to his/her medications, diet, activity level, etc.

  Example: When Sarah went to visit her family doctor this week, he told her she had “high blood pressure and added a new medication.”

OBJETIVE FINDINGS

Document objective data including blood pressure and/or blood glucose readings, and findings from physical assessment (i.e., noticeable scraps or cuts, tearfulness, etc.).

Example: TC checked Henry’s blood pressure log and found his last three readings were 122/78, 120/76, and 122/80. 

​ASSESSMENT FINDINGS

Document your interpretation of the subjective and objective findings.

Example: Cortney met with a dietician last week to discuss how to follow a diabetic diet. Cortney stated an understanding and compliance with following a diabetic diet. However, her personal assistant reported that Cortney was eating a ½ gallon of ice cream weekly and drinking a 2L of pop daily.

PLAN

• Document plan on addressing assessment finding (address each abnormal finding).

  Example: Create food diary with Cortney and follow-up weekly. Take Cortney grocery shopping weekly and teach her how to read food labels and choose healthy foods.

• Report any issues or barriers to implementing this action plan.

  Example: The nearest grocery store with a variety of fresh fruits and vegetables is 45 minutes away.

• Document follow-up to action items.

  Example: TC re-visited Sammy a month later and found he was behind on his electric bill for the second consecutive month. Sammy did not open up a bank account as discussed the previous month.