MEDICAL RECORDS DOCUMENTATION

  SOAP FORMAT should be used in  all medical records.

S(Subjective)  -  Patient Reported Data
 - What the patient says
 - “Been on diabetic diet prior to admission”
 -  Summary of eating prior to admission (solid, liquid)
 -  Height and weight (if stated by patient)
 -   Appetite
 -   Food allergies

O(Objective)  -  Factual Information Which Can Be Confirmed/Verified
 - Diet prescribed for patient
 - Diagnosis
 - Height and weight (actual)
 - Ideal body weight (IBW)
 - Physical signs of malnutrition
 - Pertinent laboratory values
 - Pertinent  medications
 - Diet history taken
 - Diet instructional materials given
 - Attendance in dietary patient education classes
 - What you actually did with the patient

A(Assessment)  -  Evaluation/Interpretation of S & O
 - Ability of patient to correctly select menu items using diet
 - Goal for weight loss
 - Understanding of diet
 - Motivation to follow diet (home, hospital, both)
 - Nutritional therapy - whether the patient should gain, lose or maintain weight
  on prescribed diet
 - Whether patient needs more protein or calories
 - If more nutritional assessment is needed, whether the diet is correct for the
  patient's nutritional needs
 - Anticipated problems in patient’s complying with diet
 - Appropriateness of diet order
 - Expected compliance
 - Evaluation of nutritional status
 - Assessment of current diet (24 hr recall

P(Plan)  - Course of Action Based on S, O & A
 - Required follow-up
 - Request for patient to attend Dietary Patient Education Classes
 - Recommendations - Increase calories, add supplements
 - Goal for weight loss
 
 

                                                        CHARTING EXERCISES

Identify each of the following statements as S.O.A. or P..

Charting Exercise:  Identify each of the following statements as S.O.A. or P.
By:  Carla Tiolo

__1. Diagnosis: Insulin Dependent Diabetes Mellitus
__2. “I like to eat salty foods”
__3. Pt. is compliant to sodium restricted diet
__4. IBW-160#
__5. Will teach pt. portion sizes on next outpatient visit
__6. Drinks 1L of water daily
__7. Pt. has been n.p.o. for 3 days
__8. History of colon cancer
__9. Instructed pt. on low-fat diet
__10. Contact physician about exercise program
__11. FPG 120mg/dl
__12. “I drink 2% milk”
__13. Diet history reveals pt. diet is inadequate for good blood glucose control
__14. Pt. c/o 15# wt. loss in last 2 months.
__15. Pt. is interested and motivated to learn about diet
__16. HDL Cholesterol-35mg/dl
__17. Experiences indigestion after meals
__18. Pt. should maintain current wt. of 130# on 2,000 cal.    Diet
__19. Meds. include Coumadin and Lasix
__20. Pt. was present for all dietary education classes
__21. Allergic to wheat products
__22. Diagnosis: Myocardial Infarction
__23. Review of 24hour recall reveals pt. skipped lunch
__24. Bruises easily
__25. Hgb-15mg/dl

Compose a SOAP note from the following scenarios.

Scenario #1
M.L. is a 64 y.o. female admitted to the hospital c/o SOB and severe chest pain.  Her PH shows a hx of HTN.  Dx: Acute MI.  Other pertinent information includes a cholesterol of 260 mg/dl; ht. 5'5" and a current wt. of 156 lb.  She was placed on the medications Procardia and a 2 gm sodium, low fat, no caffeine diet.  The physician requested a nutrition consult.  You assessed her IBW at 125 lb which is 125% of IBW, and calorie needs at 1200 kcal to promote a weight loss of 1-2# per week and reduce blood cholesterol levels.  Diet history reveals that the patient followed no special diet PTA except to cut down on salt.  She routinely consumes foods like cheese, whole milk, and high fat snacks.  Pt. admits to gaining weight over the past few years due to "not watching my diet" and getting little exercise.  You instructed ML on the diet prescription.  Since the physician did not recommend a calorie restriction, you wanted to let him know of your recommendation.  It seems as if ML was open to the counseling and seemed motivated since she does not want to have a heart attack.  ML tells you that she is open to starting an exercise program.

Identify the relevant information from the above scenario as S. O. A. or P.

S:
 
 
 

O:
 
 
 
 
 

A:
 
 
 
 
 

P:
 
 
 
 

Scenario #2

44 yo F referred to outpatient clinic with a dx of Type 2 diabetes.  The physician ordered a diabetic diet..   Pt. Ht. 5'5"; wt. 240 #; medium frame size.  IBW 125#, %IBW  192.  Calorie needs for gradual wt loss assessed at 1420 kcal.  Actual calorie intake, approximately 2000 kcal.  1400 kcal diet will promote a 1-2# wt loss per week.  Diet is adequate in vitamins and minerals.  PMH Type 2 diabetes 2 months.  She is not taking any medications and there were no labs available for assessment.  Nutrtion hx reveals pt has followed wt loss diets previously but has gained over 80# in the past few years.  Pt states that since she was diagnosed with diabetes that she has tried to modify her food intake and lost about 5# in the last 2 months.  Blood glucose levels are 230 mg/dL.  Pt eats 3 meals per day but does not eat at regular times.  She lives with her elderly mother. Recommend 1400 calorie restriction to diabetic diet order.   Pt. displays a good understanding of diet and appears motivated to lose weight.  Goals for this patient are to lose 1-2# per week, increase exercise,  per physician approval and to normalize blood sugar.

Identify the relevant information from the above scenario as S. O. A. or P.

S:
 
 
 

O:
 
 
 
 
 

A:
 
 
 
 
 

P:
 
 
 
 
 
 
 
 

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