SOAP notes

[Meenah]

Calling on the nurses here!!! I am having trouble with soap notes. I have never used them, and am now learning for school. Yesterday I actually spent 6 hours putting together my soap note on one of the patients I had seen in clinical. It ended up looking like a very extensive H&P, my HPI & Objctive section seemed the same thing just written differently. Do any of you have any tips or could you suggest a book that will help me? I cannot believe I am having this much trouble. Thanks.
Luanne

[Cumberland]

We use this ( but minus the references):

FNP SOAP Outline Guidelines

ADULT

Date of encounter
S: Chief Complaint
HPI
Past Medical History
Family History
Personal/Social History
Health Maintenance HX
ROS

O: Physical exam

A: Part 1: Complete problem list for medical, social, and emotional (each)
Part 2: Problem discussion for priority for medical, social, and emotional (each)
Part 3: Analysis and Differential Dx. discussion for each

P: Pharmaceutical plan
Therapeutic actions
Educational/Health Promotion activities
Diagnostics
Critical guidelines
Consultations

References (2) serving as evidence for practice

PEDS

Date of encounter

S: CC and HPI
Birth History
Nutrition/Elimination/Growth and Development/Sleep
Immunization history
Parent-child relationship
Family History and Family Assessment
Past Medical Hx

O: Physical exam

A: Part 1: Complete problem list for medical, social, and emotional (each)
Part 2: Problem discussion for priority for medical, social, and emotional (each)
Part 3: Analysis and Differential Dx. discussion for each

P: Medical Plan: Pharmaceutical plan
Therapeutic actions
Educational activities
Diagnostics
Critical guidelines
Consultations

Anticipatory Guidance
Immunizations given
Other

References (2) serving as evidence for practice

GERON

Date of encounter
S: Chief Complaint
HPI
Past Medical History
Family History
Personal/Social History
Medication list
Functional Assessment
ROS
Health Maintenance HX

O: Physical exam

A: Part 1: Complete problem list for medical, social, and emotional (each)
Part 2: Problem discussion for priority for medical, social, and emotional (each)
Part 3: Analysis and Differential Dx. discussion for each

P: Pharmaceutical plan
Therapeutic actions
Educational/Health Promotion activities
Diagnostics
Critical guidelines
Consultations

References (2) serving as evidence for practice

GYN

Date of encounter
S: Chief Complaint
HPI
Past Medical History
Family History
Personal/Social History
Health Maintenance HX
ROS
GYN history: Menstrual hx
Sexual Hx
Contraceptive hx
Obstetric hx
Menopausal hx
GYN: Paps, procedures, STDs
Other

O: Physical exam

A: Part 1: Complete problem list for medical, social, and emotional (each)
Part 2: Problem discussion for priority for medical, social, and emotional (each)
Part 3: Analysis and Differential Dx. discussion for each

P: Pharmaceutical plan
Therapeutic actions
Educational/Health Promotion activities
Diagnostics
Critical guidelines
Consultations

References (2) serving as evidence for practice

[smiley]

I know that they have examples of SOAP notes in the book First Aid for the wards, but I don't know if nursing ones should be different or not. It couldn't hurt to look though.

[Meenah]

Thanks so much
Luanne