Patient Encounter Documentation

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OBJECTIVES
At the conclusion of this chapter, the student will be able to
1.Understand the components of each section of the SOAP note
2.Organize the subjective section of the SOAP note to provide a concise, chronological account of the
history of present illness
3.Accurately document the patient encounter utilizing the SOAP note format
KEY TERMS
History and physical examinations (H&Ps)
SOAP note
Subjective
Objective
Assessment
Plan
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All patient encounters require accurate documentation. This comes in many forms. The typical outpatient
encounter is documented utilizing the format of subjective, objective, assessment, and plan (SOAP note).
The same pattern when used for daily inpatient encounters is referred to as a progress note. Patients
require expanded histories and comprehensive physical exams when first admitted to the inpatient setting,
when being seen as new patients at outpatient clinics, or routinely at age-appropriate intervals. These
comprehensive evaluations are called history and physical examinations (H&Ps).
History and physical examinations: evaluation of the patient through attainment of a complete medical
history and the performance of a comprehensive physical examination
SOAP Note Documentation
Every patient encounter requires documentation not only to preserve the event as related to the care and
future reference for the patient, but also for billing and legal purposes. The SOAP note, most frequently
used in outpatient documentations, records the history obtained, the physical examination performed, the
assessment in the form of a differential diagnosis, and the plan for investigation and treatment.
SOAP note: standardized documentation format for patient encounters consisting of four sections:
subjective, objective, assessment, and plan
WRITING THE SOAP NOTE
Legibility in documentation is very important and is made easier through the advancement of electronic
medical records (EMRs). Even though providers may follow the standard of care in diagnosis and
treatment of the patient, when charts are reviewed where bad outcomes have been encountered, illegible
notes appear sloppy and allow for misinterpretation to occur: Sloppy writing translates to sloppy patient
care.
Each note must begin with the date and time of the encountera medical, legal, and coding necessity. A
well-written note becomes an accurate account of the patients current illness followed by his/her general
medical history. This is followed by your findings from the physical examination. Your assessment is a
list of possible diagnoses that demonstrate your thought processes and interpretation of the history and
exam. You finish the document with what you plan to do for the patient, not only immediately but in the
long term as well.
The note should be complete and concise, providing a reader unfamiliar with the case with a detailed,
easily understood picture of the patient encounter. Only appropriate abbreviations should be used within
the SOAP note. Avoid nonstandard abbreviations.

FIGURE 19-1 The standard SOAP note format contains four sections: subjective, objective, assessment,
and plan.
SOAP NOTE FORMAT
The standard SOAP note format with components is shown in FIGURE 19-1.
Subjective
The subjective section of the SOAP note contains only the history that was obtained from the patient
encounter. This is the patients story, collected through the CODIERS SMASH FM mnemonic tool. By
carefully interviewing the patient, you will try to obtain the most thorough and accurate information
possible. You may quote the patient directly. Phrases such as fluid on the lungs or a cancer in the
belly are acceptable once you have done your best to obtain more precise information: heart failure and
gastric carcinoma. By the same token, the patients ability to recall dates may not be precise. Patients may
only remember that they had a tonsillectomy as a child or that they had asthma that went away in high
school, and you may record the information as it is presented to you.
Subjective: section of the SOAP note containing the chief complaint, patient demographics, and history
obtained from the patient encounter
The subjective section always begins with the chief complaint and should be concise, describing the
symptoms, diagnosis, or other reasons for the encounter, and in the patients own words as often as is
practical. The following is an example of how chief complaints should be documented:

Subjective 7/21/09 1310

CC: Nasal congestion and frontal HA 5 days
After the chief complaint the CODIERS portion of the history is recorded in paragraph form. Start with
the patient demographics, giving the patients age, race, and gender: 19 y/o CF complaining of The
rest of the history of the present illness should complete a paragraph giving all of the pertinent
information from CODIERS.

Subjective 7/21/09 1310

CC: Nasal congestion and frontal HA 5 days

S: 19 y/o CF (demographics) presents c/o nasal congestion with thick green rhinorrhea 5 days.
Also c/o b/l frontal HA 3 days, increased with bending over, postnasal drainage, and cough with
green sputum production, especially in the am. Rates HA with a 5/10 intensity. No prior history of
the same. Denies sore throat, fever, chills, sob, ear or neck pain.

When you first start writing SOAP notes, it may be difficult to decide exactly which information to
include. You may start by following the CODIERS questions very closely, converting the answers to
declarative sentences. As you gain skill in creating the narrative of SOAP notes, you should find that you
are thinking ahead to the assessment and plan while writing down the subjective material. With practice,
the SOAP will become a cohesive story from start to finish.
Once you are able to decide in advance what you want to express in the assessment and plan, you will
have a better idea of what will be needed in your subjective to support it. For example, if you believe that
a patient with coughing, sneezing, and a runny nose has a cold, you should carefully describe the
symptoms that convinced you of the diagnosis (pertinent positives) and then include all of the factors that
helped you decide that the patient did not have other conditions associated with each of those symptoms,
such as allergies or sinusitis (pertinent negatives).
The SMASH FM information should consist of short lists of information in outline format. The individual
initials do not have any specific meaning in the world of medical documentation so you need to write out
the words they stand for or use an accepted abbreviation. Documenting M: Diabetes will not be
intelligible to anyone, so you should write out Medical History: Diabetes.
Once again it is important to include the negative information. You may know that the patient has never
been hospitalized, but no one else will until you write it out. It is also important to remember to be very
specific in asking patients their history to be sure to get the exact information you are seeking. A perfectly
compliant patient might tell you that he/she has no medical conditions, no medications, and no surgeries
and then tell you that he/she has been hospitalized for pneumonia twice in the last year, but only if you
ask.
Subjective 7/21/09 1310

CC: Nasal congestion and frontal HA 5 days

S: 19 y/o CF presents c/o nasal congestion with thick green rhinorrhea 5 days. Also c/o b/l frontal
HA 3 days, increased with bending over, postnasal drainage, and cough with green sputum
production, especially in the am. Rates HA with a 5/10 intensity. No prior history of the same.
Denies sore throat, fever, chills, sob, ear or neck pain.

Social Hx: Tobacco: ppd 4 years

Alcohol: None
Occupation: College freshman
FLDNMP: 1 week ago

Medical Hx: Otitis mediachildhood

Allergies: None

Surg Hx: B/L ear tubes at 4 y/o

Family Hx: No contacts with similar symptoms

Medications: Birth control pill

A frequently seen error is putting CODIERS under Subjective and SMASH FM under Objective, where
the physical examination belongs, and then completely omitting the physical exam from documentation.
Avoid this mistake.
Objective
Under objective, begin with documenting the vital signs provided to you from the patient data sheet. If
you repeat any vitals, mark them as such: Repeated vitals: BP 132/76 Right arm.
Objective: section of the SOAP note documenting the finding of the physical examination performed on
the patient
The next lines should contain the problem-specific physical examination in outline format with headings
for each part of the system exam. Unless the chief complaint is very minor and the patient extremely
healthy (a splinter in the finger of a 12-year-old child), assessment of the heart and lungs is almost always
included.
Your examination should be written up in the following format:
Objective

WDWN CF in no apparent distress

T-99.0F, P-88, R-16, BP-160/94, Repeated BP-136/82 R arm

Skinwarm and dry w/o rash

HeadNC, frontal sinus tenderness to palp and percussion b/l

EarsTMs gray b/l with good light reflex

Nosemucosa edema and erythema with green exudate

Pharynxminimal erythema, green PND. No tonsillar hypertrophy.

Neckw/o lymphadenopathy

LungsCTA w/o wheezes, crackles

HeartRRR w/o murmur, rub, or gallop

An ideal physical examination would include every positive finding that helps confirm the most likely
diagnosis and any negative findings that help to exclude other items in the differential. Be very careful not
to write anything in the physical exam that you did not actually do. It is preferable to write not assessed
rather than deferred, which has some ambiguity. If a patient refuses part of the examination, it should
be noted as refused or declined by patient.
Assessment
The assessment is the differential diagnosis and should be numbered in order of likelihood. For our
patient with coughing, sneezing, and runny nose, you could write simply:
Assessment: section of the SOAP note documenting the differential diagnosis derived from the patient
encounter in order of likelihood
Assessment
1.URI
2.Rule out rhinosinusitis
3.Doubt seasonal allergies
The first item in the differential should be the most likely and should never be preceded by rule out. If
the diagnosis is not known, the presenting symptoms can be documented. For example, if a patient
presents with a cough of unknown etiology, the first diagnosis would be cough, not rule out
pneumonia. If, however, through your physical findings you identify pneumonia as the cause of the
cough, your first entry would be Pneumonia.
Additional suspected diagnoses that require further investigation can be entered with rule out or R/O.
If there is no actual complaint in the reason for the patients visit, you should list preexisting medical
problems, health maintenance issues, or risk factors appropriate to the patients age and reason for the
visit. For example, a 50-year-old diabetic male presents for a yearly physical examination that is required
for him to drive a school bus. He smokes, has an allergy to bee stings, and is noted to have a mild
elevation of his blood pressure with no history of prior elevation. Your assessment might include items
such as:
Assessment
1) Diabetes mellitus (preexisting medical condition)
2) Tobacco use disorder (risk factor)
3) Elevated BP without diagnosis of hypertension (risk factor)
4) Bee sting allergy (preexisting condition)
5) Colorectal cancer screening (health maintenance issue)
Plan
The first priority in the plan section should be to give a well-thought-out course of treatment for the
diagnosis you believe is most likely and to include as many elements of proper medical care as possible.
You may also rule out secondary diagnoses as appropriate. For example, in a patient with a likely URI,
strep pharyngitis could be addressed and ruled out effectively with a simple notation of throat culture in
the plan.
Plan: section of the SOAP note documenting the proposed treatment plan for the patient
MOTHRR.
Using the mnemonic MOTHRR covers all of the elements needed to construct a complete plan for the
patient. MOTHRR stands for:
Medicines
Osteopathic treatment
Testing
Holistic/Humanistic items
Referrals
Return plan
Not every aspect of this mnemonic is required for every case, but you should at least think of each
category as you decide on the appropriate treatment for your patients. Remember also that the letters used
in the mnemonic are not standard medical abbreviations, requiring you to either write out the individual
headings or simply number the items that address each of the categories. Do not write out the initials M-
O-T-H-R-R as headings.

Medications. Document the drug name, dose, frequency, amount dispensed, number of refills, and
specific instructions that were shared with the patient.
Ibuprofen 600 mg PO three times a day with food, Disp #30, 1 refill.

Osteopathic treatment. For each diagnosis consider if osteopathic manipulation is appropriate. If so, be
certain you have documented the dysfunction necessitating manipulation within the physical examination
and the differential. Document the intervention, noting areas of treatment, techniques, and outcome on
reassessment.

Testing. Testing includes all of the tests you want to order to confirm the diagnosis, rule out less likely
diagnoses, and guide your treatment plan. This includes such things as blood work, radiological studies,
and specialized tests performed by other providers.

Holistic/Humanistic. Holistic/Humanistic items show your concern for the patient as a whole and
demonstrate that you are thinking of the patient as a person rather than as a simple diagnosis. Classic
examples include asking if the patient would like to include a relative, friend, or other support person in
the discussion of diagnosis and building of a treatment plan, or asking questions that indicate that you are
thinking about how the current illness is affecting the patients life by interfering with work or the
activities of daily living. These questions should be asked of every patient. Writing in your plan that you
are going to take steps to overcome these problems allows you to give concrete evidence that you have
considered these matters carefully.

Referral. Referral is another area where you will not always have anything to add. If you are convinced
that you need the help of a specialist to take care of the patient, then by all means ask for one, but do not
order excessive consultations simply to have something to put in this category.

Return Plan. The return plan is the last thing to address. If the patient is to be admitted to the hospital, a
return plan may not be appropriate until the outcome of the admission is known. In all other instances,
you should indicate the follow-up plan to see the patient. Whether a day or a year later, as a dedicated
provider who is committed to making certain the patient has received optimal care, you will need to
follow up with the patient.

Plan

Medications: Amoxicillin 500 mg tid 14 days

OMM: Frontal sinus drainage techniques applied b/l

Holistic: Increase fluids, return to work in 2 days

Return Plan: Nursing to call in 3 days to reassess. Patient to call earlier with increase in headache,
fever, change in vision, no improvement.
The complete SOAP note may be similar to this example.
Subjective 7/21/09 1310

CC: Nasal congestion and frontal HA 5 days

S: 19 y/o CF presents c/o nasal congestion with thick green rhinorrhea 5 days. Also c/o b/l frontal
HA 3 days, increased with bending over, postnasal drainage, and cough with green sputum
production, especially in the am. Rates HA with a 5/10 intensity. No prior history of the same.
Denies sore throat, fever, chills, sob, ear or neck pain.

Social Hx: Tobacco: ppd 4 years

Alcohol: None
Occupation: College freshman
FLDNMP: 1 week ago
Medical Hx: Otitis mediachildhood

Allergies: None

Surg Hx: B/L ear tubes at 4 y/o

Family Hx: No contacts with similar symptoms

Medications: Birth control pill

Objective

WDWN CF in no apparent distress

T-99.0F, P-88, R-16, BP-160/94, Repeated BP-136/82 R arm

Skinwarm and dry w/o rash

HeadNC, frontal sinus tenderness to palp and percussion b/l

EarsTMs gray b/l with good light reflex

Nosemucosa edema and erythema with green exudate

Pharynxminimal erythema, green PND. No tonsillar hypertrophy.

Neckw/o lymphadenopathy

LungsCTA w/o wheezes, crackles

HeartRRR w/o murmur, rub or gallop

Assessment
1.Sinusitis
2.URI
3.Doubt seasonal allergies
4.Tobacco use disorder

Plan

Medications: Amoxicillin 500 mg tid 14 days

OMM: Frontal sinus drainage techniques applied b/l

Holistic: Increase fluids, return to work in 2 days

Return Plan: Nursing to call in 3 days to reassess. Patient to call earlier with increase in headache,
fever, change in vision, no improvement.
Complete History and Physical Examination
The full history and physical examination follow essentially the same format as the SOAP note, with
expansion of details (see FIGURE 19-2). The subjective section is replaced by the terminology History
of Present Illness but contains the exact same components of CODIERS. Though symptoms associated
with the CC are still present in the HPI, an additional screening called the review of symptoms (ROS) is a
general survey of all body systems and is not based on the presenting complaint. SMASH FM is
expanded to include more details in the social history, medical history with immunizations, and surgical,
hospitalization, and family history. Assessment and plan remain the same.
FIGURE 19-2 History and physical examination format.
FIGURE 19-3 Sample of a complete history and physical examination.