What should be included in a SOAP note template for a new admission from a nurse practitioner?

SOAP Note Template for New Admission from a Nurse Practitioner

A comprehensive SOAP note template for a new admission should include structured sections for Subjective, Objective, Assessment, and Plan information, with particular attention to vital signs monitoring, risk assessment, and clear documentation of the treatment plan.

Subjective (S)

• Chief complaint/reason for admission 1
• History of present illness including:
  • Emergency symptoms (headache, visual disturbances, chest pain, dyspnea, neurological symptoms, abdominal pain, nausea, anorexia) 1
  • Duration of symptoms 1
  • Previous treatments and response 1
• Past medical history 1
• Medication history:
  • Current medications with last dose taken 1
  • Medication sensitivities/allergies 1
  • Compliance with medications 1
• Social history:
  • Use of recreational drugs or other BP raising medications 1
  • Socioeconomic factors affecting care 1
• Review of systems 2
• Patient's understanding of their condition 1

Objective (O)

• Vital signs:
  • Blood pressure (in both arms at first visit, using proper technique) 1
  • Heart rate 1
  • Respiratory rate 1
  • Temperature 1
  • Oxygen saturation 1
• Level of consciousness (AVPU or ACDU score) 1
• Physical examination findings:
  • Cardiovascular exam 1
  • Respiratory exam 1
  • Neurological exam 1
  • Abdominal exam 1
  • Extremity exam (edema, peripheral pulses) 1
• Laboratory results:
  • Complete blood count 1
  • Electrolytes 1
  • Renal function tests 1
  • Cardiac biomarkers (if relevant) 1
  • Other pertinent labs 1
• Diagnostic test results:
  • ECG findings 1
  • Imaging results 1
  • Other relevant diagnostic information 1

Assessment (A)

• Primary diagnosis 2, 3
• Secondary diagnoses/comorbidities 2
• Problem list (prioritized) 3
• Clinical status assessment 1
• Risk stratification:
  • ASCVD risk assessment (if applicable) 1
  • Risk factors for complications 1
• Functional status 1
• Cognitive status assessment 1

Plan (P)

• Treatment plan for each identified problem 2, 3:
  • Pharmacological interventions 1
  • Non-pharmacological interventions 1
  • Monitoring parameters 1
• Diagnostic plan:
  • Additional tests needed 1
  • Consultations required 1
• Education plan:
  • Patient/family education provided 1
  • Self-management instructions 1
• Follow-up plan:
  • Monitoring schedule 1
  • Follow-up appointments 1
  • Criteria for reassessment 1
• Discharge planning (if applicable):
  • Anticipated discharge date 1
  • Post-discharge needs 1
  • Coordination with other healthcare providers 1

Important Considerations for SOAP Documentation

• Document the date and time of the assessment 1
• Include your signature, credentials, and contact information 1
• Ensure bidirectional communication between facilities when applicable 1
• Use clear, concise language avoiding abbreviations that could be misinterpreted 4
• Document any changes from baseline or previous assessments 1
• Include interdisciplinary team input when relevant 1
• Document patient's response to interventions 1

Common Pitfalls to Avoid

• Failing to document vital signs properly (proper positioning, appropriate cuff size) 1
• Omitting key components of the physical examination 1
• Not addressing each problem identified in the assessment section 3
• Inadequate documentation of patient education provided 1
• Lack of specific follow-up plans for each problem 2
• Insufficient documentation of medication reconciliation 1
• Not documenting the patient's understanding of their condition and plan 1