How do you write a SOAP (Subjective, Objective, Assessment, Plan) assessment for a patient with Parkinson's disease?

Writing a SOAP Assessment for Parkinson's Disease

Assessment Section Structure

The assessment section of a SOAP note for a patient with Parkinson's disease should clearly document disease severity, motor and non-motor symptoms, functional status, and treatment response using standardized rating scales and objective findings.

Key Components to Include

1. Disease Classification and Staging

• Document the Hoehn and Yahr stage (I-V) to classify disease progression 1, 2

  • Stage I: Unilateral involvement with minimal impairment
  • Stage II: Bilateral involvement without balance impairment
  • Stage III: Mild to moderate bilateral disease with postural instability
  • Stage IV: Severe disability, still able to walk or stand unassisted
  • Stage V: Wheelchair bound or bedridden unless assisted

• Specify disease pattern: tremor-predominant, akinetic-rigid, or mixed phenotype 1

2. Motor Symptom Assessment

• Document presence and severity of the four cardinal motor symptoms 3:

  • Bradykinesia: Specify severity and affected body regions
  • Resting tremor: Note 4-6 Hz frequency, asymmetry, and whether it decreases during voluntary movement
  • Rigidity: Document increased muscle tone and resistance to passive movement
  • Postural instability: Note impaired balance and coordination

• Include UPDRS Part III (motor) score if available 2

  • Provides objective measurement of 14 motor items with maximum score of 108
  • Higher scores indicate worse motor function

3. Non-Motor Symptom Assessment

• Document presence and severity of common non-motor symptoms:
  • Cognitive status: Note any impairment, especially executive dysfunction
  • Mood disorders: Depression, anxiety, apathy
  • Sleep disturbances: REM sleep behavior disorder, insomnia, excessive daytime sleepiness
  • Autonomic dysfunction: Orthostatic hypotension, constipation, urinary symptoms
  • Sensory symptoms: Pain, olfactory dysfunction

4. Functional Status Assessment

• Document impact on activities of daily living using UPDRS Part II score if available 2

  • Assesses 13 ADL items with maximum score of 52
  • Higher scores indicate greater functional impairment

• Note specific functional limitations:

  • Mobility: Walking difficulties, freezing of gait, falls
  • Self-care: Dressing, bathing, feeding difficulties
  • Fine motor tasks: Writing, handling utensils, opening containers

5. Treatment Response Assessment

• Document response to dopaminergic therapy 4, 5:

  • ON/OFF fluctuations: Duration and severity
  • Wearing-off phenomena: Timing relative to medication doses
  • Dyskinesias: Type, timing, and severity

• Note current medication regimen effectiveness:

  • Levodopa response: Excellent, good, partial, or poor
  • Motor complications from long-term therapy

6. Dysphagia Assessment

• Document swallowing function, especially for patients with 6:
  • Hoehn & Yahr stage above II
  • Weight loss or low BMI (<20 kg/m²)
  • Drooling or sialorrhea
  • Cognitive impairment
  • Any signs of swallowing difficulties

7. Nutritional Status

• Document weight changes, BMI, and nutritional concerns 6
• Note any vitamin deficiencies, particularly vitamin D, B12, and folate

Sample Assessment Format

"Patient presents with Parkinson's disease, Hoehn & Yahr stage ___, characterized by [asymmetric/symmetric] involvement with [predominant symptom pattern]. UPDRS motor score is ___ (if available), showing [mild/moderate/severe] bradykinesia affecting [body regions], [resting/postural/kinetic] tremor that is [present/absent] at rest and [increases/decreases] with movement, [mild/moderate/severe] rigidity in [affected limbs], and [present/absent] postural instability.

Non-motor manifestations include [cognitive status], [mood symptoms], [sleep disturbances], [autonomic symptoms], and [sensory symptoms]. Functionally, patient [is/is not] independent in ADLs with specific difficulties in [areas of impairment]. Patient [does/does not] experience motor fluctuations with [good/partial/poor] response to current dopaminergic therapy. [If applicable: Dysphagia assessment reveals...]. Nutritional status is [stable/declining] with BMI of ___."

Common Pitfalls to Avoid

1. Failing to use standardized rating scales (UPDRS, Hoehn & Yahr) to objectively document disease severity 2

2. Overlooking non-motor symptoms, which significantly impact quality of life 7

3. Not documenting medication response patterns, which are crucial for treatment adjustments 4, 5

4. Missing dysphagia assessment in at-risk patients, which is associated with pneumonia risk 6

5. Neglecting to assess fall risk, especially in patients with postural instability 3

6. Failing to document the impact of symptoms on functional status and quality of life 7