How to Document SOFA Score in Medical Records
Document the SOFA score by recording each of the six organ system components individually (respiratory, cardiovascular, hepatic, coagulation, renal, neurological) with their respective 0-4 point scores, followed by the total score (0-24 points), the date and time of calculation, and any change from baseline (delta SOFA). 1, 2
Essential Components to Document
Individual Organ System Scores (0-4 points each)
Respiratory: Record PaO2/FiO2 ratio with the actual value and corresponding score (0 points: ≥400 mmHg; 1 point: <400; 2 points: <300; 3 points: <200 with mechanical ventilation; 4 points: <100 with mechanical ventilation) 3, 1
Cardiovascular: Document mean arterial pressure (MAP) and any vasopressor requirements with doses in mcg/kg/min (0 points: MAP ≥70 mmHg; 1 point: MAP <70; 2 points: dopamine ≤5 or dobutamine any dose; 3 points: dopamine >5 OR epinephrine ≤0.1 OR norepinephrine ≤0.1; 4 points: dopamine >15 OR epinephrine >0.1 OR norepinephrine >0.1) 3, 1
Hepatic: Record bilirubin level in mg/dL (0 points: <1.2; 1 point: 1.2-1.9; 2 points: 2.0-5.9; 3 points: 6.0-11.9; 4 points: ≥12.0) 3
Coagulation: Document platelet count in ×10³/μL (0 points: ≥150; 1 point: <150; 2 points: <100; 3 points: <50; 4 points: <20) 3
Renal: Record creatinine in mg/dL and urine output (0 points: <1.2; 1 point: 1.2-1.9; 2 points: 2.0-3.4; 3 points: 3.5-4.9; 4 points: ≥5.0 or renal replacement therapy) 3
Neurological: Document Glasgow Coma Scale score (0 points: GCS 15; 1 point: GCS 13-14; 2 points: GCS 10-12; 3 points: GCS 6-9; 4 points: GCS <6) 3
Critical Documentation Elements
Timing and Context
Calculate using the most abnormal values from the first 24 hours of ICU admission for baseline SOFA score 2, 4
Record the exact date and time of calculation to enable tracking of score trajectory 3, 1
Document baseline SOFA score (pre-admission or at admission) to calculate delta SOFA, which is the change from baseline and independently predicts mortality 5, 6
Total Score and Clinical Interpretation
Record total SOFA score (sum of all six components, range 0-24 points) prominently in the medical record 1, 2
Document if SOFA increased ≥2 points from baseline in the presence of suspected or documented infection, as this defines sepsis per Sepsis-3 criteria and triggers immediate intervention 1, 2, 4
Note the maximum SOFA score achieved during ICU stay, as this is the strongest predictor of mortality (area under curve 0.91) 2, 5, 6
Practical Documentation Format
Recommended Structure in Case Sheet
Write the SOFA score documentation as follows:
"SOFA Score (Date/Time):
- Respiratory: [score] (PaO2/FiO2 = [value])
- Cardiovascular: [score] (MAP = [value], vasopressors: [details])
- Hepatic: [score] (Bilirubin = [value])
- Coagulation: [score] (Platelets = [value])
- Renal: [score] (Creatinine = [value], UOP = [value])
- Neurological: [score] (GCS = [value])
- Total SOFA: [sum]/24
- Baseline SOFA: [value] (date)
- Delta SOFA: [change from baseline]"
Serial Monitoring Documentation
Reassess and document SOFA scores every 48-72 hours throughout ICU stay to track disease progression and treatment response 3, 1, 4
Document trajectory: Note whether scores are increasing (poor prognosis), decreasing (improved survival), or stable 3, 2, 4
Special Considerations for Emergency Mass Critical Care
In declared emergencies or mass casualty events, document that a state of emergency exists and note that SOFA scoring is being used for triage purposes 3
Record that all existing resources and surge capacity have been maximized before using SOFA for resource allocation decisions 3
Document triage category based on SOFA score if applicable (scores >11 may indicate palliative care priority in resource-limited scenarios) 3, 2
Common Pitfalls to Avoid
Do not use outdated terminology such as "severe sepsis" - this term is obsolete per Surviving Sepsis Campaign guidelines 1
Ensure accurate FiO2 retrieval for respiratory scoring, as this is the most common source of automated calculation errors 7
For dialysis patients with normal creatinine but no urine output, assign 4 points for renal component to avoid underscoring 7
Do not rely on SOFA alone for triage decisions in routine clinical practice, as it lacks validation for resource allocation at low scores and does not account for age or comorbidities 2, 4
Document the specific vasopressor doses in mcg/kg/min rather than just "on pressors" to enable accurate cardiovascular scoring 3