What is the SOAP (Subjective, Objective, Assessment, Plan) outline for a geriatric patient?

From the Guidelines

A SOAP note for a geriatric patient should prioritize a comprehensive assessment of their medical conditions, functional status, and social factors, guided by the Geriatric 5Ms framework, as outlined in the clinician's guide to geriatric assessment 1. To create an effective SOAP outline for a geriatrics case, consider the following key components:

• Subjective section: document the chief complaint, history of present illness, past medical history, medications (including over-the-counter and supplements), allergies, social history (living situation, support systems, alcohol/tobacco use), and review of systems focusing on geriatric syndromes like falls, incontinence, and cognitive changes.
• Objective section: record vital signs, physical examination findings (with attention to cognitive assessment, gait/balance, vision/hearing, and skin integrity), and relevant laboratory or diagnostic results.
• Assessment section: list active problems in order of priority, including both acute issues and chronic conditions, with special attention to geriatric syndromes, polypharmacy concerns, and functional limitations, using the Geriatric 5Ms framework to manage the patient's care 1.
• Plan section: address each problem with specific interventions, medication adjustments (considering age-appropriate dosing, potential interactions, and deprescribing opportunities), preventive care recommendations (vaccinations, cancer screenings based on life expectancy), functional goals, follow-up appointments, and care coordination needs, prioritizing the patient's mind, mobility, medications, what matters most to the patient, and multicomplexity 1. By following this structured approach, clinicians can ensure comprehensive care that addresses the complex, interrelated medical and social needs of older adults, reducing disability, hospitalization, and institutionalization, and improving quality of life, as supported by the study published in the Mayo Clinic Proceedings 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Geriatrics Case SOAP Outline

To create a SOAP (Subjective, Objective, Assessment, Plan) outline for a geriatrics case, consider the following elements:

• Subjective:
  • Patient's medical history, including current medications and allergies 2, 3
  • Social and environmental factors that influence overall well-being 2, 3
  • Patient's goals of care and life expectancy 2
• Objective:
  • Medical evaluation, including assessment of functional status, fall risk, nutrition, vision, hearing, cognition, mood, and toileting 2, 3
  • Use of validated assessment tools, such as the Beers, STOPP, and START criteria for medication review 2
  • Screening for depression, unintentional weight loss, and malnutrition 2
  • Assessment of urinary incontinence and cognitive function 2, 3
• Assessment:
  • Comprehensive geriatric assessment (CGA) to identify medical, social, and functional needs 4, 5
  • Evaluation of patient's frailty and its impact on outcomes 4, 5
  • Identification of areas for focused intervention to improve quality of life 2, 3
• Plan:
  • Development of a coordinated and integrated care plan to meet patient's needs 4, 5
  • Implementation of interventions to address identified problems, such as medication management, fall prevention, and cognitive support 2, 3
  • Consideration of patient's goals of care and life expectancy when developing the plan 2
  • Regular follow-up and reassessment to monitor patient's progress and adjust the plan as needed 2, 3