What is the proper SOAP note—including history questions, physical exam, labs, imaging, assessment, and plan—to use for every emergency inpatient admission?

Emergency Inpatient Admission SOAP Note Framework

Every emergency inpatient admission requires immediate stabilization of airway, breathing, and circulation (ABCs) as the first priority, followed by rapid structured assessment using standardized severity scoring, targeted history, focused physical examination, and time-sensitive laboratory and imaging studies to establish diagnosis and guide treatment. 1, 2

Initial Stabilization and Triage (First Hour)

Immediate Actions:

• Assess and stabilize airway, breathing, circulation 1, 2
• Obtain vital signs: heart rate, blood pressure, respiratory rate, temperature, oxygen saturation 3, 2, 4
• Calculate early warning score (NEWS or equivalent) to determine need for senior review or ICU consultation 1
  • Score ≥5-6 or single parameter score of 3: urgent clinician review
  • Score ≥7: immediate critical care team assessment
• Document Glasgow Coma Scale (GCS) for baseline neurological status 3, 1
• Perform structured neurological assessment (NIHSS if stroke suspected) 3, 2

Subjective (History) - Critical Elements

Time-Sensitive Information:

• Symptom onset time or last known normal time (crucial for time-dependent interventions) 3, 2
• Initial symptoms and progression 3
• Previous functional status and independence level 2

Focused Medical History:

• Vascular risk factors: hypertension, diabetes, hypercholesterolemia, smoking 3
• Current medications with emphasis on:
  • Anticoagulants (warfarin, DOACs) 3, 2
  • Antiplatelet agents (aspirin, clopidogrel) 3
  • Antihypertensives 3
  • Stimulants, decongestants, sympathomimetics 3
• Recent trauma or surgery (particularly carotid procedures) 3
• Substance use: alcohol, cocaine, illicit drugs 3
• Relevant comorbidities:
  • Dementia (amyloid angiopathy risk) 3
  • Liver disease (coagulopathy) 3
  • Cancer/hematologic disorders (coagulopathy) 3
  • Chronic respiratory disease 4
  • Cardiac disease 5
• Seizure history 3, 2
• Allergies (particularly beta-lactam antibiotics) 1
• Advanced care directives 2

For Specific Presentations:

• Chest pain: character, location, severity, radiation, associated symptoms 5
• Neurological symptoms: focal deficits, headache, altered consciousness 3
• Infectious symptoms: fever onset, rash progression, neck stiffness 1

Objective (Physical Examination)

Vital Signs Documentation:

• Temperature (fever associated with neurological deterioration) 3
• Blood pressure (initial BP >220/120 mmHg significant; for thrombolysis candidates: contraindicated if SBP ≥185 or DBP ≥110) 2
• Heart rate and rhythm 2
• Respiratory rate and effort 4
• Oxygen saturation on room air or supplemental oxygen (document FiO2) 2, 4
• Hydration status 2

Targeted Physical Examination:

• General appearance: distress level, skin color (cyanosis, pallor), perfusion 4
• Head/Neck:
  • Pupillary response 3
  • Fundoscopy if safe (papilledema) 1
  • Neck stiffness (meningismus) 1
  • Airway assessment (tonsillar hypertrophy, mandibular hypoplasia, Mallampati score) 6
• Cardiovascular: heart sounds, murmurs, peripheral pulses, capillary refill (<2 seconds normal) 1
• Respiratory: breath sounds, work of breathing, chest wall movement 4
• Neurological:
  • GCS score 3, 1
  • NIHSS for stroke patients 3, 2
  • Focal deficits 3, 2
  • Seizure activity 2
• Skin: rash presence/progression (meningococcal sepsis) 1
• Extremities: edema, warmth, motor/sensory function 3

Assessment (Labs and Imaging)

Immediate Laboratory Studies (Within 1 Hour):

• Blood cultures (before antibiotics if sepsis/meningitis suspected) 1
• Complete blood count (thrombocytopenia assessment) 3, 2
• Electrolytes 3, 2
• Glucose (hyperglycemia associated with hematoma expansion and worse outcomes) 3, 2
• Renal function: BUN, creatinine (elevated creatinine associated with hematoma expansion) 3, 2
• Coagulation studies:
  • PT/INR 3, 2
  • aPTT 3, 2
• Cardiac biomarkers if chest pain/ACS suspected: troponin, CK-MB 5
• Arterial blood gas if:
  • Suspected hypercapnia 4
  • Oxygen saturation concerns (pulse oximetry overestimates in darker skin pigmentation) 7
  • Unexplained confusion/agitation 4

Additional Labs Based on Presentation:

• Liver function tests if coagulopathy suspected 3
• Toxicology screen if substance use suspected 3
• Carboxyhemoglobin if carbon monoxide poisoning suspected 4

Imaging Studies:

Immediate (Stat) Imaging:

• CT head without contrast for:
  • Suspected stroke (distinguish ischemic vs hemorrhagic) 3, 8, 2
  • Suspected intracerebral hemorrhage 3, 8
  • Altered mental status with focal findings 3
  • Before lumbar puncture if: focal neurological signs, papilledema, continuous seizures, GCS ≤12 1

Urgent Imaging:

• Chest X-ray for respiratory symptoms 4
• ECG for chest pain/cardiac symptoms 5
• CT angiography if vascular pathology suspected (PE, aortic dissection) 5

Plan

Immediate Interventions (First Hour):

Oxygen Therapy:

• Target saturation 94-98% for most patients 4
• Target saturation 88-92% for COPD/hypercapnic risk patients 4
• Use reservoir mask if severe hypoxemia 4
• Position patient upright if conscious and hypoxemic 4

Time-Dependent Treatments:

• Sepsis/Meningococcal disease:
  • Antibiotics immediately after blood cultures 1
  • Fluid resuscitation: 500 mL crystalloid bolus initially 1
  • Target: capillary refill <2 seconds, mean BP >65 mmHg, normal mental status, urine output >0.5 mL/kg/hour 1
• Meningitis without sepsis:
  • Lumbar puncture within 1 hour if safe 1
  • Antibiotics immediately after LP (or after blood cultures if LP delayed) 1
• Stroke:
  • Thrombolysis consideration if within 4.5-hour window 2
  • EVT consideration if within 6-24 hour window (selected patients) 2
• Intracerebral hemorrhage:
  • Reverse anticoagulation immediately if INR elevated 3, 8
  • Platelet transfusion if severe thrombocytopenia 3, 8

Blood Pressure Management:

• Non-thrombolysis stroke candidates: Lower only if SBP >220 or DBP >120 2
• Thrombolysis candidates: Must achieve SBP <185 and DBP <110 before treatment 2
• Hemorrhagic stroke: Follow specific hemorrhagic stroke guidelines 8

Seizure Management:

• Single self-limited seizure at stroke onset: no long-term anticonvulsants 2
• Active seizures: short-acting medications (lorazepam IV) 2
• Monitor for recurrence 2

Disposition Planning:

• Senior clinician review within 14 hours (earlier for critical patients) 1
• ICU consultation if NEWS ≥7 or clinical deterioration 1
• Neurology/neurosurgery consultation for stroke/ICH 8
• Infectious disease consultation for complex infections 1

Documentation Requirements:

• Time-based record of all medications: name, route, site, time, dose/kg, patient effect 6
• "Time out" before procedures: confirm patient name, procedure, laterality/site 6
• Continuous monitoring documentation: consciousness level, vital signs, oxygen saturation 6
• Discharge criteria assessment 6

Critical Pitfalls to Avoid

• Never delay imaging or treatment to obtain complete history in unstable patients 1, 2
• Never discontinue oxygen to obtain room air saturation in patients requiring oxygen 4
• Never perform LP without neuroimaging if focal signs, papilledema, continuous seizures, or GCS ≤12 1
• Never delay antibiotics for LP in septic patients 1
• Never rely solely on pulse oximetry in patients with dark skin pigmentation (may overestimate saturation) 7
• Never give pre-hospital sedation prescriptions without direct supervision (unacceptable risk) 6
• Double-check all weight-based medication calculations with second individual 6