How to SOAP a critically ill patient?

SOAP Documentation for Critically Ill Patients

The most effective approach to SOAP documentation for critically ill patients requires a structured format that prioritizes airway management, monitoring, and team communication to reduce mortality and improve quality of life.

Subjective Component

• Document the patient's presenting symptoms with attention to respiratory complaints, pain, anxiety, and communication difficulties 1
• Record the patient's medical history, focusing on conditions that may affect airway management (previous intubation difficulties, COPD, sleep apnea) 1
• Note the patient's emotional state, as critically ill patients often experience anxiety, alienation, and panic which can affect recovery 1
• Document any communication barriers due to mechanical ventilation or altered consciousness 1

Objective Component

• Record vital signs with particular attention to oxygen saturation, respiratory rate, and hemodynamic parameters 1
• Document airway assessment findings using a validated tool such as the MACOCHA score to predict difficult intubation 1
• Include detailed physical examination focused on the respiratory system, noting any signs of respiratory distress 2
• Document the results of capnography monitoring, which is essential for all intubated patients and can prevent up to 70% of ICU airway-related deaths 1
• Record the depth of tracheal tube insertion and cuff pressure (20-30 cm H₂O) if the patient is intubated 1
• Note patient positioning, especially for obese patients (ramped position with external auditory meatus level with sternal notch) 1

Assessment Component

• Provide diagnostic reasoning and differential diagnoses for the patient's condition 3, 2
• Document the severity of illness using validated scoring systems (e.g., SOFA score) 4
• Assess the risk of difficult airway management, particularly in obese patients who have twice the risk of complications 1
• Evaluate the effectiveness of current ventilation strategies and oxygenation status 1
• Document the risk of ventilator-associated pneumonia and other hospital-acquired infections 5
• Assess the patient's response to sedation and need for sedation holds, noting the risks in patients with difficult airways 1

Plan Component

Airway Management Plan

• Document a clear primary intubation strategy (Plan A) including positioning, preoxygenation technique, and medication choices 1
• Include rescue strategies (Plans B/C) using supraglottic airway devices or facemask ventilation if intubation fails 1
• Document a front-of-neck airway access plan (Plan D) for cannot-intubate, cannot-oxygenate scenarios 1
• Specify team roles for airway management, including first intubator, drug administrator, monitor observer, equipment assistant, and team leader 1

Ventilation Strategy

• Document ventilation parameters including mode, PEEP, tidal volume, and FiO₂ 1
• Include weaning protocol if applicable, as therapist-driven protocols can reduce duration of mechanical ventilation 1
• Consider non-invasive ventilation strategies for appropriate patients, which can reduce intubation rates in certain conditions 1

Monitoring Plan

• Specify continuous monitoring requirements including waveform capnography for all intubated patients 1
• Document the frequency of airway assessments and tube position checks 1
• Include a plan for monitoring during high-risk periods such as patient repositioning, transfers, or procedures 1

Communication Plan

• Document handover information for the healthcare team, highlighting difficult airway status 1
• Include bedside signage requirements for patients with difficult airways 1
• Specify team briefing requirements before procedures 1

Common Pitfalls to Avoid

• Failing to sign SOAP notes (occurs in 36.8% of student documentation) 2
• Documenting subjective symptoms under the objective component (occurs in 27.4% of cases) 2
• Omitting physical examination findings or documenting them inaccurately (accurate in only 9.5% of notes) 2
• Neglecting to document airway assessment and difficult airway status 1
• Failing to use waveform capnography for intubated patients, which contributes to >70% of ICU airway-related deaths 1
• Inadequate documentation of treatment plans (accurate in only 38% of notes) 2
• Omitting team roles and responsibilities during critical procedures 1

Special Considerations for COVID-19 Patients

• Document PPE requirements including fitted respirator masks (N95 or equivalent) for aerosol-generating procedures 1
• Specify the need for negative pressure rooms when possible 1
• Note that endotracheal aspirates are preferred over bronchoalveolar lavage for diagnostic sampling 6