Long-Term Care Survey Alert
Check Out This Sample SOAP Note From The RAI User's Manual
PDF
Documentation captures subjective, objective info.
The following example shows the SOAP method in action for day one of an initial admission from the hospital for Mr. S:
The following SOAP note was written on admission.
S: "Come sit with me, Joanne. I am so thirsty. Get me some water," says Mr. S to wife Marion. (Joanne is his sister who expired 12 years ago.) Wife stated that he never refers to her as his sister, but that since he was admitted to the hospital, he has been more confused.
O: Mr. S admitted from the hospital, s/p left hip replacement. Mr. S has a five-year history of Alzheimer's disease, and has been attending the Cognitive Impairment Clinic at the hospital for three years. According to hospital discharge summary, Mr. S was agitated in the ER, and was given Haldol IM several times during his stay in the hospital. His dehydration was treated successfully with IV fluids.
He was "very confused, more so than what the wife previously indicated." Other new medications include ranitidine (Zantac), Morphine, Bactrim DS for a diagnosed urinary tract infection. He remained restrained throughout his stay. Mr. S is oriented only to self and responds to his name only. He refers to his wife as his sister (new for him). He is not aware that he is in a nursing facility or that he was in a hospital. He continuously picks at his bedclothes, and fidgets with the call light.
A: Acute confusion possibly related to hospitalization, medications, urinary tract infection, pain and isolation.
P: Monitor closely for safety. Do not use restraints. Begin 15 minute checks while awake. Encourage out of room activities. Resident continuing on Bactrim DS for six more days. Consult with physician about medication regimen. Ask daughter to bring in some of Mr. S' favorite articles to reorient him. Encourage frequent visits from family, explaining to them about Mr. S' change in cognitive status. Monitor closely for hip pain. Medicate with Tylenol for discomfort. Maintain pain flow sheet in the clinical record to assess effectiveness of pain regimen.
Source: RAI user's manual, Chapter 4.
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