SOAP Note Example for Nursing Home Patient
A comprehensive SOAP note for a nursing home patient should include detailed assessment of physical, cognitive, and psychosocial status, with particular attention to mobility, fall risk, pain management, and mental health concerns.
Subjective (S)
- Chief complaint or reason for visit
- Current symptoms and concerns expressed by patient
- Pain assessment (location, intensity using validated scale, quality, timing, aggravating/relieving factors)
- Sleep patterns and any disturbances
- Mood and emotional status
- Appetite and nutritional intake
- Elimination patterns (bowel and bladder function)
- Activity level and participation in facility programs
- Social interactions with staff, other residents, and visitors
- Patient's goals and preferences for care
Objective (O)
- Vital signs (temperature, pulse, respiration, blood pressure, oxygen saturation)
- Weight and nutritional status assessment
- Physical examination findings focused on:
- Skin integrity and presence of pressure injuries
- Mobility status and gait assessment
- Neurological status (including cognition using validated tools)
- Cardiopulmonary assessment
- Musculoskeletal assessment (joint range of motion, strength)
- Fall risk assessment using validated tool
- Medication review and adherence
- Laboratory and diagnostic test results
- Functional status assessment (ADLs, IADLs)
- Mental status examination
- Pain assessment using objective scale
Assessment (A)
- Primary diagnoses with current status
- Secondary diagnoses and comorbidities
- Identification of active problems requiring intervention
- Evaluation of fall risk factors
- Assessment of pressure injury risk
- Cognitive and mood status assessment
- Nutritional status assessment
- Pain management effectiveness
- Progress toward established goals
- Identification of new concerns or complications
- Diagnostic reasoning for current presentation
Plan (P)
- Medication adjustments or renewals
- Specific interventions for identified problems
- Pain management strategies
- Fall prevention interventions
- Pressure injury prevention or treatment
- Referrals to specialists or therapy services (PT, OT, speech)
- Nutritional interventions
- Mental health interventions
- Patient and family education needs
- Follow-up schedule and monitoring parameters
- Advanced care planning discussions
Special Considerations for Nursing Home SOAP Notes
Mobility and Fall Prevention
Document comprehensive fall risk assessment and specific preventive measures including positioning, supportive devices, and environmental modifications 1. Include daily stretching plans for hemiplegic limbs and proper positioning techniques to prevent contractures.
Mental Health Assessment
Include depression screening using validated tools, assessment for delirium using tools like the Confusion Assessment Method, and evaluation for pseudobulbar affect in post-stroke patients 1. Document behavioral symptoms and potential triggers, especially in patients with dementia.
End-of-Life Considerations
For patients receiving palliative care, document comprehensive assessment of physical symptoms, emotional status, and unresolved personal issues 1. Include discussions about goals of care and advance directives.
Environmental and Cultural Factors
Document how the nursing home environment impacts the patient's condition, including homelike qualities, presence of children/pets/plants, and opportunities for autonomy and decision-making 1. Note how staffing patterns and facility culture affect the patient's care.
Sleep Assessment
Document sleep patterns, factors contributing to sleep disturbances (pain, nocturia, environmental disruptions), and interventions to improve sleep quality 1. For patients with dementia, note any circadian rhythm disturbances.
Medication Appropriateness
Include assessment of medication appropriateness, particularly for frail nursing home residents, identifying potentially inappropriate medications that could be considered for deprescribing 1.
By following this comprehensive SOAP note format, healthcare providers can ensure thorough documentation of nursing home patients' complex needs while facilitating effective communication among the interdisciplinary care team.