episodic and comprehensive soap note write up samples
episodic and comprehensive soap note write up samples
Write Ups
The written History and Physical (H&P) serves several purposes:
- It is an important reference document that provides concise information about a patient’s history and exam findings at the time of admission.
- It outlines a plan for addressing the issues which prompted the hospitalization. This information should be presented in a logical fashion that prominently features all of the data that’s immediately relevant to the patient’s condition.
- It is a means of communicating information to all providers who are involved in the care of a particular patient.
- It allows students and house staff an opportunity to demonstrate their ability to accumulate historical and examination-based information, make use of their medical fund of knowledge, and derive a logical plan of attack.
The H&P is not:
- An instrument designed to torture Medical Students and Interns.
- Meant to cover unimportant/unrelated information.
- Should not require so much time to write that by the time it’s submitted, the information contained within is obsolete!
Knowing what to include and what to leave out will be largely dependent on experience and your understanding of illness and pathophysiology. If, for example, you were unaware that chest pain is commonly associated with coronary artery disease, you would be unlikely to mention other coronary risk-factors when writing the history. As you gain experience, your write-ups will become increasingly focused. You can accelerate the process by actively seeking feedback about all the H&Ps that you create as well as by reading those written by more experienced physicians. Several sample write-ups are presented at the end of this section to serve as reference standards.
ORDER YOUR CUSTOM PAPER NOW
The core aspects of the H&P are described in detail below.
Chief Concern (CC):
One sentence that covers the dominant reason(s) for hospitalization. While this has traditionally been referred to as the Chief Complaint, Chief Concern may be a better description as it is less pejorative and confrontational sounding.
“CC: Mr. Smith is a 70 year-old male admitted for the evaluation of increasing chest pain.”
History of Present Illness (HPI):
The HPI should provide enough information to clearly understand the symptoms and events that lead to the admission. This covers everything that contributed to the patient’s arrival in the ED (or the floor, if admission was arranged without an ED visit). Events which occurred after arrival can be covered in a summary paragraph that follows the pre-hospital history.
A commonly used pneumonic to explore the core elements of the chief concerns is OLD CARTS, which includes: Onset, Location, Duration, Characteristics, Aggravating/Alleviating factors, Related symptoms, Treatments, and Significance.
Some HPIs are rather straight forward. If, for example, you are describing the course of a truly otherwise healthy 40-year-old who presents with 3 days of cough, fever, and shortness of breath as might occur with pneumonia, you can focus on that time frame alone. Writing HPIs for patients with pre-existing illness(es) or a chronic, relapsing problems is a bit trickier. In such cases, it’s important to give enough relevant past history “up front,” as having an awareness of this data will provide the contextual information that allows the reader to fully understand the acute issue. If, for example, a patient with a long history of coronary artery disease presents with chest pain and shortness of breath, an inclusive format would be as follows:
“HIP: Mr. S is a 70 yr old male presenting with chest pain who has the following coronary artery disease related history:
-Status Post 3 vessel CABG in 2008.
-Suffered recurrent chest pain in December 2015, which ultimately lead to catheterization and stent placement in a mid-LAD lesion.
-He was re-cathed in January 2017 for recurrent chest pain at rest; at that time there was no significant change compared to catheterization of 12/15. The patient was therefore continued on medical therapy.
-Known to have an Ejection Fraction of 40% with inferior and lateral akinesis by echo in January 2018
-No prior episodes of heart failure.
-Last Exercise Tolerance Test was performed in January of 2018 and showed no ischemia at 8 METS of activity.Mr. S was in his usual state of health until last week (~ Saturday, November 18), when he began to experience recurrent episodes of chest pain, exactly like his past angina, after walking only one block. This represented a significant change in his anginal pattern, which is normally characterized as mild discomfort which occurs after walking vigorously for 8 or 9 blocks. In addition, 1 day prior to admission, the pain occurred while he was reading a book and resolved after taking a nitroglycerin tablet. It lasted perhaps 1 minute. He has also noted swelling in his legs over this same time period and has awakened several times in the middle of the night, gasping for breath. In order to breathe comfortably at night, Mr. S now requires the use of 3 pillows to prop himself up, whereas in the past he was always able to lie flat on his back and sleep without difficulty. Mr. S is known to have poorly controlled diabetes and hypertension. He currently smokes 2 packs of cigarettes/day. He denies fevers, chills, cough, wheezing, nausea vomiting, recent travel, or sick contacts.”
That’s a rather complicated history. However, it is obviously of great importance to include all of the past cardiac information “up front” so that the reader can accurately interpret the patient’s new symptom complex. The temporal aspects of the history are presented in an easy to follow fashion, starting with the most relevant distant event and then progressing step-wise to the present.
From a purely mechanical standpoint, note that historical information can be presented as a list (in the case of Mr. S, this refers to his cardiac catheterizations and other related data). This format is easy to read and makes bytes of chronological information readily apparent to the reader. While this data is technically part of the patient’s “Past Medical History,” it would be inappropriate to not feature this prominently in the HPI. Without this knowledge, the reader would be significantly handicapped in their ability to understand the patient’s current condition.
Knowing which past medical events are relevant to the chief concern takes experience. In order to gain insight into what to include in the HPI, continually ask yourself, “If I was reading this, what historical information would I like to know?” Note also that the patient’s baseline health status is described in some detail so that the level of impairment caused by their current problem is readily apparent.
The remainder of the HPI is dedicated to the further description of the presenting concern. As the story teller, you are expected to put your own spin on the write-up. That is, the history is written with some bias. You will be directing the reader towards what you feel is/are the likely diagnoses by virtue of the way in which you tell the tale. If, for example, you believe that the patient’s chest pain is of cardiac origin, you will highlight features that support this notion (e.g. chest pressure with activity, relieved with nitroglycerin, preponderance of coronary risk factors etc.). These comments are referred to as “pertinent positives.” These details are factual and no important features have been omitted. The reader retains the ability to provide an alternative interpretation of the data if he/she wishes. A brief review of systems related to the current complaint is generally noted at the end of the HPI. This highlights “pertinent negatives” (i.e. symptoms which the patient does not have). If present, these symptoms might lead the reader to entertain alternative diagnoses. Their absence, then, lends support to the candidate diagnosis suggested in the HPI. More on the HPI can be found here: HPI.
Occasionally, patients will present with two (or more) major, truly unrelated problems. When dealing with this type of situation, first spend extra time and effort assuring yourself that the symptoms are truly unconnected and worthy of addressing in the HPI. If so, present them as separate HPIs, each with its own paragraph.
Past Medical History (PMH):
This includes any illness (past or present) that the patient is known to have, ideally supported by objective data. Items which were noted in the HPI (e.g. the cardiac catheterization history mentioned previously) do not have to be re-stated. You may simply write “See above” in reference to these details. All other historical information should be listed. Important childhood illnesses and hospitalizations are also noted.
Detailed descriptions are generally not required. If, for example, the patient has hypertension, it is acceptable to simply write “HTN” without providing an in-depth report of this problem (e.g. duration, all meds, etc.). Unless this has been a dominant problem, requiring extensive evaluation, as might occur in the setting of secondary hypertension.
Also, get in the habit of looking for the data that supports each diagnosis that the patient is purported to have. It is not uncommon for misinformation to be perpetuated when past write-ups or notes are used as the template for new H&Ps. When this occurs, a patient may be tagged with (and perhaps even treated for) an illness which they do not have! For example, many patients are noted to have Chronic Obstructive Pulmonary Disease (COPD). This is, in fact, a rather common diagnosis but one which can only be made on the basis of Pulmonary Function Tests (PFTs). While a Chest X-Ray and smoking history offer important supporting data, they are not diagnostic. Thus, “COPD” can repeatedly appear under a patient’s PMH on the basis of undifferentiated shortness of breath coupled with a suggestive CXR and known smoking history, despite the fact that they have never had PFTs. So, maintain a healthy dose of skepticism when reviewing notes and get in the habit of verifying critical primary data.
Past Surgical History (PSH):
All past surgeries should be listed, along with the rough date when they occurred. Include any major traumas as well.
Medications (MEDS):
Includes all currently prescribed medications as well as over the counter and non-traditional therapies. Dosage, frequency and adherence should be noted.
Allergies/Reactions (All/RXNs):
Identify the specific reaction that occurred with each medication.
Social History (SH):
This is a broad category which includes:
- Alcohol Intake: Specify the type, quantity, frequency and duration.
- Cigarette smoking: Determine the number of packs smoked per day and the number of years this has occurred. When multiplied this is referred to as “pack years.” If they’ve quit, make note of when this happened.
- Other Drug Use: Specify type, frequency and duration.
- Marital/Relationship Status; Intimate Partner Violence (IPV) screen.
- Sexual History, including: types of activity, history of STIs.
- Work History: type, duration, exposures.
- Other: travel, pets, hobbies.
- Health care maintenance: age and sex appropriate cancer screens, vaccinations.
- Military history, in particular if working at a VA hospital.
Family History (FH):
This should focus on illnesses within the patient’s immediate family. In particular, identifying cancer, vascular disease or other potentially heritable diseases among first degree relatives
Obstetrical History (where appropriate):
Included the number of pregnancies, live births, duration of pregnancies, complications. As appropriate, spontaneous and/or therapeutic abortions. Birth control (if appropriate).
Review of Systems (ROS): As mentioned previously, many of the most important ROS questions (i.e. pertinent positives and negatives related to the chief concern) are generally noted at the end of the HPI. The responses to a more extensive review, covering all organ systems, are placed in the “ROS” area of the write-up. In actual practice, most physicians do not document an inclusive ROS. The ROS questions, however, are the same ones that are used to unravel the cause of a patient’s chief concern. Thus, early in training, it is a good idea to practice asking all of these questions so that you will be better able to use them for obtaining historical information when interviewing future patients. A comprehensive list can be found here: ROS
Physical Exam:
Generally begins with a one sentence description of the patient’s appearance.
Vital Signs:
HEENT: Includes head, eyes, ears, nose, throat, oro-pharynx, thyroid.
Lymph Nodes:
Lungs:
Cardiovascular:
Abdomen:
Rectal (as indicated):
Genitalia/Pelvic:
Extremities, Including Pulses:
Neurologic:
- Mental Status
- Cranial Nerves
- Motor
- Sensory (light touch, pin prick, vibration and position)
- Reflexes, Babinski
- Coordination
- Observed Ambulation
Lab Results, Radiologic Studies, EKG Interpretation, Etc.:
Assessment and Plan:
It’s worth noting that the above format is meant to provide structure and guidance. There is no gold standard, and there’s significant room for variation. When you’re exposed to other styles, think about whether the proposed structure (or aspects thereof) is logical and comprehensive. Incorporate those elements that make sense into future write-ups as you work over time to develop your own style
SAMPLE WRITE UP #1
ADMISSION NOTE
CC: Mr. B is a 72 yo man with a history of heart failure and coronary artery disease, who presents with increasing shortness of breath, lower extremity edema and weight gain.
HPI: His history of heart failure is notable for the following:
- First MI was in 2014, when he presented w/a STEMI related to an LAD lesion. This was treated w/a stent. Echo at that time remarkable for an EF 40%.
- Despite optimal medical therapy, he had a subsequent MI in 2016. At that time, cardiac catheterization occlusions in LAD, OMB, and circumflex arteries. No lesions were amenable to stenting. An echo was remarkable for a dilated LV, EF of 20-25%, diffuse regional wall motion abnormalities, 2+MR and trace TR.
- Heart failure symptoms of DOE and lower extremity edema developed in 2017. These have been managed medically with lisinopril, correg, lasix and metolazone.
Over the past 6 months he has required increasing doses of lasix to control his edema. He was seen 2 weeks ago by his Cardiologist, Dr. Johns, at which time he was noted to have worsening leg and scrotal edema. His lasix dose was increased to 120 bid without relief of his swelling.
Over the past week he and his wife have noticed a further increase in his lower extremity edema which then became markedly worse in the past two days. The swelling was accompanied by a weight gain of 10lb in 2 days (175 to 185lb) as well as a decrease in his exercise tolerance. He now becomes dyspneic when rising to get out of bed and has to rest due to SOB when walking on flat ground. He has 2 pillow orthopnea, but denies PND.
Denies CP/pressure, palpitations or diaphoresis. Occasional nausea, but no vomiting. He eats normal quantities of food but does not salt or fluid intake. He also admits to frequently eating canned soup, frozen meals, and drinking 6-8 glasses liquid/day. He has increased urinary frequency, but decreased total amount of urine produced. He denies urinary urgency, dysuria or hematuria. He has not noted cough, sputum, fever or chills. He states he has been taking all prescribed medications on most days – missing a few (? 2-3) doses a week.
| PMH: | CHF- as above MI 2014, 2016 HTM Chronic renal insufficiency from DM nephropathy: Cr 1.8 1/2018 Diabetes: controlled with Metformin – a1c 6.8 2/2018 |
|---|---|
| PSH: | Appendectomy 1992 Cholecystectomy 2004 |
| MEDS: | Lasix 120 mg BID Correg 25 bid Lisinopril 40 qd KCl 40 meq qd Dabigatran 200 mg qd Metformin 1g bid ASA 81mg qd Atorvastatin 40 mg/d |
| Allergies: | No Known Drug Allergies |
| Social History: | Married for 45 years, sexual active with wife. Three children, 2 grandchildren, all healthy and well; all live within 50 miles. Retired school teacher. Enjoys model car building. Walks around home, shopping but otherwise not physically active. episodic and comprehensive soap note write up samples |
| Smoking: | None |
| Alcohol: | None |
| Other substance use: | None |
| Military service: | Marine Corp x 4 years, non-combat. Worked logistics. |
| Family History: | + sister and mother with DM, father with CAD, age onset 50. Brother with leukemia. |
| ROS | General: Denies fatigue, fever, chills, weight loss; + weight gain as above HENT: Denies oral sores, neck masses, nasal d/c, hearing problems Vison: Denies change in vision, eye pain, redness, discharge Cardiac: As above Pulmonary: As above GI: Denies heart burn, swallowing difficulty, abdominal pain, diarrhea, constipation GU: As per HPI Neuro: Denies seizure, weakness, numbness Endo: Denies heat/cold intolerance, weight changes, polyuria, polydipsia Heme/Onc: Denies unusual bleeding, bruising, clotting MSK: Denies join pain, swelling, muscle aches Mental Health: Denies anxiety, depression, mood changes, Skin/Hair: Denies rashes, non-healing wounds, ulcers, hair loss |
| PE: | VS: T 97.1, P65, BP 116/66, O2Sat 98% on 2L NC Weight 187lbs GEN: elderly man lying in bed with head up, NAD HEENT: NCAT, multiple telangiectasias on face and nose; EOMI, PERRLA, Oropharynx w/o lesions, mucous membranes moist; thyroid not palpable, no adenopathy Pulmonary: +dullness to percussion at right base, + crackles 1/2 way up chest bilateral posteriorly Cardio: RRR, +2/6 holosystolic murmur at apex radiating to axilla, +S3, no S4; PMI displaced laterally toward axilla; carotid pulses 2+ B, no bruits; JVP 12cm Abdomen: +BS, non-distended, nontender, no hepatomegaly. Extremities: 3+ edema to sacrum, abdominal wall and scrotum; no clubbing, cyanosis, no skin breaks distally episodic and comprehensive soap note write up samples Pulses: 2+femoral B, 1+ PT/DP B Neuro: Mental status: alert and appropriate Motor: 5/5 all extremities Sensory: distal sensation in legs intact to light touch, pin prick; proprioception toes normal bilaterally; vibration intact at IP joint bilateral great toes Reflexes: 2+ and symmetric bilaterally: biceps, triceps, brachioradialis, patellar, achilles Gait: not observed |
| Labs and Data: | Na 128, C1 96, Bun 59, Glucose 92, K 4.4, CO2 40.8, CR 1.4, WBC 7.9, PLT 349, HCT 43.9, Alk phos 72, Total Protein 5.6, Alb 3.5, T Bili 0.5, Alt 17, Ast 52, Troponin < .01, BNP 1610. EKG: Sr at 74, q-waves v1-v5, no st-t wave changes. No change compared with study of 6m ago. CXR: Prominent pulmonary vessels with moderate interstitial edema and right pleural effusion. Cardiomegaly. No parenchymal infiltrates. |
| Assessment and Plan: | 72-year-old man with history of HFrEF following multiple Mis, admitted with sub-acute worsening edema and DOE. His symptoms are most consistent with increasing heart failure, which would account for both his pulmonary congestion as well as his peripheral edema. His renal disease is a less likely explanation for his extensive edema as his BUN/Cr have remained stable throughout. Elevated BNP is also consistent w/heart failure.
The question is why his heart failure has become refractory to treatment? Possibilities include: 1) worsening LV function, 2) another MI, 3) worsening valvular disease, 4) poor compliance with medications and/or 5) excess salt and water intake. There is no evidence by history, EKG, or enzymes for current ischemia/infarct. And his valvular disease does not appear severe enough to be causing symptoms. Given this, the most likely precipitant of his failure is a combination of dietary indiscretion and poor adherence with medications in a patient with a severely depressed EF.
|
SAMPLE WRITE-UP #2
ADMISSION NOTE
CC: Mr. S is a 65-year-old man who presents with 2 concerns:
1. Acute, painless decline in vision
2. Three day history of a cough.
HPI:
1. Visual changes: Yesterday morning, while eating lunch, the patient had the sudden onset of painless decrease in vision in both eyes, more prominent on the right. Onset was abrupt and he first noted this when he “couldn’t see the clock” while at a restaurant. He also had difficulty determining the numbers on his cell phone. He denied pain or diplopia. Did not feel like a “curtain dropping” in front of his eyes. He had nausea and vomiting x2 yesterday, which has resolved. He did not seek care, hoping that the problem would resolve on its own. When he awoke this morning, the same issues persisted (no better or worse) and he contacted his niece, who took him to the hospital. At baseline, he uses prescription glasses without problem and has no chronic eye issues. episodic and comprehensive soap note write up samples Last vision testing was during visit to his optometrist 2 year ago. Notes that his ability to see things is improved when he moves his head to bring things into better view. Denies dizziness, weakness, headache, difficulty with speech, chest pain, palpitations, weakness or numbness. No history of atrial fibrillation, carotid disease, or heart disease that he knows of.
2. Cough: Patient has history of COPD with 60+ pack year smoking history and most recent PFT’s (2016) consistent with moderate disease. Over the past few days he has noted increased dyspnea, wheezing, and sputum production. Sputum greenish colored. He uses 2 inhalers, Formoterol and Tiotropium every day and doesn’t miss any dosages. He was treated with antibiotics and prednisone a few years ago when he experienced shortness of breath. He has not had any other breathing issues and no hospitalizations or ED visits. Denies hemoptysis, fevers, orthopnea, PND, chest pain or edema.
ED course: given concern over acute visual loss and known vascular disease, a stroke code was called when patient arrived in ER. Neurology service evaluated patient and CT head obtained. Data was consistent with occipital stroke, which occurred > 24 hours ago. Additional details re management described below.
| PMH: | COPD (moderate) – PFTs 2014 fev1/fvc .6, fev1 70% predicted Hypertension dx 2012 GERD Hyperlipidemia – ASCVD 12% Obstructive sleep apnea dx 2014, uses CPAP |
|---|---|
| PSH: | Right orchiectomy at age 5 for traumatic injury Right cataract removal and lens implant placement on 2014 |
| MEDS: | Asa 81 qd Lisinopril 40 mg qd Atenolol 50 mg qd Pantoprazole 20 mg po qd Tiotropium 2 puffs qd Formoterol 2 puffs qd Atorvastatin 40mg qd |
| Allergies: | None |
| Smoking: | 60 pack yr history, now 1ppd |
| Alcohol: | Heavy in past, quit 5 y ago. None currently. No know alcohol related target organ damage |
| Other substance use: | None |
| Social: | Lives with roommate in Encinitas. Heterosexual, not currently active. Never married, no children. Worked in past as architect, though currently on disability. Enjoys walking and reading. |
| Family: | Brother and father with CAD. Brother with CABG at age 55. Father with multiple strokes. Mother with DM. |
| Military service: | None |
| ROS: | General: denies fatigue, fever, chills, weight loss, weight gain HENT: denies oral sores, neck masses, nasal d/c, hearing problems Vison: as per HPI Cardiac: as per HPI Pulmonary: as per HIP GI: Denies heart burn, swallowing difficulty, abdominal pain, diarrhea, constipation GU: Denies hematuria, dysuria, nocturia, urgency, frequency Neuro: Denies seizure, weakness, numbness episodic and comprehensive soap note write up samples |
| PE: | VS: T 99 P89, irregularly irregular BP 139/63, RR 20 O2 Sat 98% RA GEN: Obese, pale man turning his head side to right side in order to see us. No acute distress HEENT: NCAT, PERRL. Discs sharp. EOMI. Visual acuity/fields as per neuro below Temporal arteries nontender. Conjunctiva clear. Neck: No adenopathy. No JVD. Carotid pulses 2+ bilaterally. Pulmonary: Moves air equally bilaterally, though wheezes on auscultation throughout. CV: irregularly irregular, II/VI systolic crescendo-decrescendo murmur at LUSB, radiating to carotids. No S3, S4. PMI not-displaced. Abd: Obese + normal BS. Soft. Nontender. Liver nonpalpable. Liver 8 cm at mid-clavicular line by percussion. Rectal: brown stool, OB neg in ER Pulses: Fem R 2+ L +1. DP 2+ B. PT 1+ B Extremities: no cyanosis, clubbing or edema. Warm, well-perfused. Neuro: AOX3; answers questions appropriately CNs: I: Able to detect coffee B nares at 10cm II: Loss of nasal field R eye, temporal field L eye by confrontation – can detect hand movement in those areas, but can’t read vision card at any line; Vision 20/40 B in fields where vision preserved (i.e. if vision card held in front of patients face towards their right) III, IV, VI: extra-ocular movements preserved in all directions. V: intact light touch all regions of face; masseter and temporalis muscles 5/5 B VII: muscles of facial expression intact VIII: hearing equal bilateral IX, X: palate symmetric XI: SCM, Trap 5/5 XII: Tongue midline Motor: Strength 5/5: biceps, triceps, grip, quad, hamstring, plantarflex, dorsiflex. F-N slight int. tremor on left. Rapid alternating movements: symmetric and equal Gait: normal Sensory: intact light touch, pin prick, vibration, proprioception at feet bilateral. Romberg negative; gait somewhat unsteady due to visual issues Reflexes: Biceps, triceps, brachioradialis: 2+ B. Patellar, achilles 2+ B; Toes down going. |
| Labs, Imaging and other Data: | Na 138, C1 106, Bun 13, Glu 99, K 4.5, CO2 25, CR 1.9, WBC 11, PLT 597, HgB 13.5, MCV 72.5, pulses P73 L16 E3 B0; Alk phos 72, T Protein 7.2, Alb 3.1, ALT 9, AST 14, LDH 123, TB 0.5, INR 1.3, TSH 2
Head CT: several, new well-demarcated infarcts in R occipitoparietal region. No evidence hemorrhage. No midline shift. CXR: no infiltrate; flattened diaphragms bilaterally consistent with COPD. EKG: A fib at 72. No acute st-t wave changes or other findings different from study 6m prior. |
| Assessment and Plan: | 65-year old man who presents with acute visual field deficits consistent with embolic stroke. Story of the sudden onset of neurologic deficits while awake, in the setting of newly identified atrial fibrillation, is most consistent with a cardio-embolic event. Artery-artery embolization is also a possibility (e.g. vertebral-basilar). Thrombosis in situ less likely, as multiple occipital infarcts are noted. Carotid stenosis not likely as retinal exam without evidence of local infarct, visual deficits indicate lesion that is after the optic chiasm, and CT w/posterior distribution infarcts. Similarly, temporal arteritis would be consideration given age and visual deficits, though lack of referable symptoms (i.e. no jaw claudication, headache, TA tenderness) and distribution of stroke makes this unlikely.
Of note, as last known normal was > 24 hours ago, he is outside the window to receive TPA or device driven therapy. No evidence of ongoing events or evolution. Focus at this time thus will be on completing diagnostic evaluation, vigilance for progression/complications, and treatment to prevent additional events.
|
