What should be included in a SOAP (Subjective, Objective, Assessment, Plan) note for a hospice patient?

SOAP Note Structure for Hospice Patients

A comprehensive SOAP note for hospice patients should focus on comfort care, symptom management, and quality of life rather than curative interventions. The documentation should reflect the palliative approach to care while addressing physical, psychological, social, and spiritual needs of both the patient and family.

Subjective Component

• Document the patient's self-reported symptoms using validated assessment tools like the Edmonton Symptom Assessment Scale (ESAS) to capture pain, dyspnea, nausea, anxiety, depression, drowsiness, appetite, wellbeing, and fatigue 1
• Record the patient's expressed goals of care, values, and preferences for end-of-life care 2
• Document any changes in symptoms since the last assessment, including onset, character, and severity using frameworks like SOCRATES (Site, Onset, Character, Radiation, Associated factors, Timing, Exacerbating/relieving factors, Severity) 3
• Include the patient's spiritual, emotional, and existential concerns 2
• Document family/caregiver observations, concerns, and their comfort level managing symptoms 1
• Note any advance directives, MOLST/POLST forms, and the patient's understanding of their prognosis 2

Objective Component

• Record vital signs with focus on parameters relevant to symptom management (respiratory rate, oxygen saturation if dyspneic) 2
• Document physical examination findings focused on areas of reported symptoms 2
• Include the Palliative Performance Scale (PPS) score to track functional status and provide prognostic information 4
• Document medication review including effectiveness of current symptom management regimens 2
• Note physical signs of approaching death when applicable (mottling, decreased urine output, changes in breathing pattern) 2
• Document laboratory or diagnostic results only if they directly impact comfort care 2

Assessment Component

• Provide an overall assessment of the patient's condition and prognosis 2
• Evaluate each symptom individually and its response to current management 2
• Assess the patient's psychological and spiritual status 2
• Document the patient's and family's understanding of the disease progression 2
• Evaluate the effectiveness of the current care plan in meeting established goals 2
• Assess family/caregiver coping and identify any support needs 5
• Document any changes in functional status using the PPS or Karnofsky Performance Status scale 4

Plan Component

• Detail specific interventions for each identified symptom, including medication adjustments with clear dosing instructions 6
• For pain management, specify regular and breakthrough analgesics with appropriate titration plans 6
• For dyspnea, include both pharmacological (opioids, benzodiazepines) and non-pharmacological interventions (positioning, fans) 2
• For psychological symptoms, document counseling approaches and medication interventions 2
• Include anticipatory guidance for the patient and family regarding expected disease progression 2
• Document any referrals to other members of the interdisciplinary team (chaplain, social worker, etc.) 7
• Specify the follow-up plan including frequency of visits and criteria for urgent contact 2
• Include education provided to the patient and family about medication administration and symptom management 5

Special Considerations

• Focus documentation on quality of life and comfort rather than disease-modifying treatments 7
• Document any discussions about sedation for intractable symptoms if applicable 2
• Include family teaching regarding signs of approaching death and appropriate responses 7
• For patients with limited life expectancy (days to weeks), document specific end-of-life care plans 2
• For patients with longer prognoses, include more emphasis on psychosocial support and quality of life 2
• Always document any changes to the goals of care based on patient/family preferences 2
• Include bereavement support planning for family members 5

By following this structured approach to SOAP documentation, hospice clinicians can ensure comprehensive, patient-centered care that addresses the multidimensional needs of patients at the end of life while maintaining clear communication among the interdisciplinary team.