Five Simple SOAP Notes for Nursing Home Patients
Below are five structured SOAP notes for common nursing home scenarios, incorporating geriatric assessment principles and appropriate documentation standards 1, 2.
Patient 1: Polypharmacy Review
Demographics: 82-year-old female
PMH: Hypertension, Type 2 Diabetes, Osteoarthritis, Depression, Chronic Kidney Disease Stage 3
S (Subjective):
- Patient reports increased dizziness over past week, especially when standing
- States "I feel confused sometimes"
- Denies chest pain or shortness of breath
- Taking 11 medications including metoprolol, lisinopril, metformin, glyburide, tramadol, sertraline
O (Objective):
- BP: 98/62 mmHg (sitting), 85/55 mmHg (standing)
- HR: 58 bpm, regular
- Blood glucose: 82 mg/dL (fasting)
- Creatinine clearance: 42 mL/min
- Mini-Cog score: 2/5 (concerning for cognitive impairment)
A (Assessment):
- Orthostatic hypotension likely medication-induced
- Polypharmacy with 11 medications creating prescribing cascade
- Hypoglycemia risk with dual diabetic agents in setting of renal impairment
- Cognitive impairment possibly related to adverse drug events
P (Plan):
- Deprescribe glyburide immediately (high-risk in renal impairment per Beers Criteria) 3
- Reduce metoprolol to 25mg daily and reassess BP in 3 days
- Hold lisinopril temporarily, recheck orthostatic vitals in 48 hours
- Medication reconciliation visit scheduled to review all 11 medications using MAI tool 3
- Monitor blood glucose QID for 1 week
- Reassess cognitive status after medication optimization
Patient 2: Frailty with Dementia
Demographics: 78-year-old male
PMH: Alzheimer's dementia (moderate), Frailty, Sarcopenia, Hypertension
S (Subjective):
- Nursing staff reports patient refusing meals for 3 days
- Estimated fluid intake <800 mL/day
- Patient states "food doesn't taste good" when prompted
- No complaints of pain or dysphagia symptoms
O (Objective):
- Weight: 58 kg (down 4 kg from last month)
- BMI: 19.2
- Skin turgor decreased, dry mucous membranes
- SARC-F score: 8/10 (sarcopenia confirmed)
- Eating Assessment Tool-10: 2/10 (negative for dysphagia)
- Daily caloric intake estimated at 900 kcal/day
A (Assessment):
- Malnutrition in frail patient with dementia
- Dehydration (inadequate fluid intake)
- Sarcopenia with ongoing muscle loss
- Risk for further functional decline without intervention
P (Plan):
- Dietitian consult today for personalized nutrition plan 4
- Target protein intake 1.2-1.5 g/kg/day (70-87g daily)
- Target caloric intake >1500 kcal/day
- Ensure fluid intake 2.0 L/day with scheduled hydration protocol 4
- Daily multivitamin supplementation (intake <1500 kcal) 4
- Check vitamin D, B12, folate levels
- Continue rivastigmine for dementia (benefits outweigh risks) 4
- Initiate multi-component exercise program with physical therapy 4
- Weekly weight monitoring
Patient 3: Fall Risk Assessment
Demographics: 85-year-old female
PMH: Osteoporosis, Parkinson's disease, Insomnia, Urinary incontinence
S (Subjective):
- Patient fell in bathroom last night at 2 AM
- Reports "I got dizzy and my legs gave out"
- Takes zolpidem 10mg nightly for sleep
- Gets up 3-4 times nightly to urinate
O (Objective):
- No acute injuries from fall, no head trauma
- BP: 142/78 mmHg (no orthostatic changes)
- Gait: shuffling, reduced arm swing, stooped posture
- Timed Up and Go test: 22 seconds (high fall risk)
- Currently on: carbidopa-levodopa, zolpidem, oxybutynin, alendronate
A (Assessment):
- Fall with injury risk in patient with multiple risk factors
- Medication-related fall risk (zolpidem, oxybutynin both Beers Criteria drugs)
- Parkinson's disease contributing to gait instability
- Nocturia increasing nighttime fall risk
P (Plan):
- Discontinue zolpidem immediately (high-risk sedative-hypnotic per Beers Criteria) 3
- Discontinue oxybutynin (anticholinergic, fall risk) 3
- Trial behavioral interventions for insomnia (sleep hygiene protocol)
- Consider mirabegron for urinary incontinence if symptoms persist
- Physical therapy evaluation for gait training and assistive device
- Bedside commode placement for nighttime use
- Environmental assessment: adequate lighting, remove trip hazards
- Vitamin D 1000 IU daily for bone health
- Fall prevention protocol with q2h rounding at night
Patient 4: Diabetes Management
Demographics: 76-year-old male
PMH: Type 2 Diabetes (20 years), Coronary artery disease, Chronic kidney disease Stage 4
S (Subjective):
- Nursing reports patient had blood glucose 52 mg/dL this morning before breakfast
- Patient was diaphoretic and confused at time
- Symptoms resolved after juice administration
- Currently on insulin glargine 40 units qHS and insulin aspart 10 units TID with meals
O (Objective):
- Fasting glucose today: 88 mg/dL (post-treatment)
- HbA1c last month: 6.2%
- Creatinine: 2.8 mg/dL, eGFR: 22 mL/min
- Weight: 72 kg (stable)
- Recent glucose log shows values 60-110 mg/dL consistently
A (Assessment):
- Severe hypoglycemia in elderly patient with advanced CKD
- Over-treatment of diabetes (HbA1c 6.2% too aggressive for this population)
- High-priority adverse drug event with insulin per national action plan 3
- Increased hypoglycemia risk due to renal impairment
P (Plan):
- Reduce insulin glargine to 20 units qHS immediately 3
- Reduce insulin aspart to 5 units TID with meals
- Adjust HbA1c target to 7.5-8.5% (appropriate for age, comorbidities, life expectancy)
- Glucose monitoring QID for 1 week, then reassess insulin doses
- Educate nursing staff on hypoglycemia recognition and treatment protocol
- Ensure bedside glucose tablets available
- Consider deprescribing insulin further if hypoglycemia recurs
- Nephrology follow-up for CKD progression
Patient 5: Pain Management Review
Demographics: 81-year-old female
PMH: Severe osteoarthritis (bilateral knees), Chronic low back pain, GERD, Atrial fibrillation on warfarin
S (Subjective):
- Patient reports pain 7/10 in knees and lower back daily
- States "the pain pills upset my stomach"
- Currently taking ibuprofen 800mg TID and tramadol 50mg QID
- Reports dark stools for past 2 days
O (Objective):
- Vital signs stable
- Abdominal exam: epigastric tenderness, no guarding
- Hemoglobin: 10.2 g/dL (baseline 12.8 g/dL 3 months ago)
- INR: 3.8 (therapeutic range 2-3)
- Stool guaiac: positive
A (Assessment):
- Likely GI bleeding from NSAID use in high-risk patient
- Polypharmacy with drug-to-drug interaction (ibuprofen + warfarin)
- Inappropriate NSAID use per Beers Criteria (on anticoagulation)
- Opioid use creating additional fall and ADE risk
- Inadequate pain control despite high-risk medication regimen
P (Plan):
- Discontinue ibuprofen immediately (contraindicated with warfarin, causing GI bleed) 3
- Hold warfarin, recheck INR tomorrow
- CBC in AM to assess for ongoing bleeding
- GI consult if hemoglobin continues to drop
- Initiate acetaminophen 1000mg TID (safer alternative)
- Reduce tramadol to 25mg TID (lower opioid burden)
- Add topical diclofenac gel to knees BID (local effect, less systemic absorption)
- Physical therapy for non-pharmacologic pain management
- Consider intra-articular steroid injections for knee OA
- PPI therapy: omeprazole 20mg daily for gastric protection
- Reassess pain control in 1 week with safer medication regimen
These SOAP notes demonstrate structured documentation incorporating geriatric assessment principles, medication safety using Beers Criteria, and deprescribing strategies appropriate for nursing home populations 3, 1, 2.