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This guide is created in order to provide examples of SOAP content for nursing and therapy as well as examples of appropriate and specific responses to applied interventions. Care should be taken to have a patient-/family- specific response to each intervention applied in order to support the case for a patient requiring a skilled need. Please review all discipline examples to clarify the needed information in each section that is not discipline specific.
RN SOC SOAP EXAMPLE
SUBJECTIVE
Pt reports he has had some drainage from the wound on his ear last night and he had to change the bandage. Pt reports he has compression stockings to wear at all times even though he is "not swollen" and reports he didn’t wear them last night and his legs were cold all night. Pt reports A1C of 7 and poor dietary intake and only takes his blood sugars daily. Pt reports that his only caregiver at this time is his provider who comes monday thru friday.
OBJECTIVE Wound to left ear has yellow slough to 75% of wound and small amount of drainage. 2+edema to bilateral lower extremity with no increase in SOB but does have history of stasis ulcers. Patient with multiple cardiovascular medications. Per patient’s blood sugar machine memory blood sugars are ranging from 80-120.
ASSESSMENT
Pt with impaired integumentary system requiring skilled nursing to perform wound care to left ear 3xweek. Patient is at risk for infection due to reported elevated A1C, blindness preventing ability to see digression in wound status and history of slowly healing wounds. Pt with impaired endocrine system requiring skilled nursing to instruct in diabetic disease process with emphasis on nutrition. Impaired cardiovascular system requiring assessment, observation, teaching and training of multiple cardiovascular medications and CHF disease process. Pt having difficulty caring for self and leaving home d/t poor vision and fear of falling as well as not wanting to leave home due to having to wound dressing on his face. His impaired vision requires someone to be with him when he leaves home and he is unable to read all of his medication bottles. He has open door ways and decent lighting but a large amount of furniture in the partial way of walkways.
PLAN Skilled nurse to request a copy of A1C lab results from Dr. Xx office. SN to provide wound care to left ear 3 x/week, instruction and education in diabetic management utilizing the diabetic education booklet beginning with page 1 and 2 focusing on the importance and purpose of insulin. Begin teaching on diabetic medications: metformin including directions for use, purpose, side effects/interactions. Include teaching and training of co-morbid conditions.
ROUTINE SOAP NOTE EXAMPLES
S : “I feel like I can’t empty my bladder.”
O : Patient is febrile at 100.4 with pain in low back 4/10.
A : Patient has symptoms consistent with UTI with increased complaints of pain and low grade fever requiring addressing, managing, and monitoring of symptoms.
P : Will follow up this afternoon with lab for results of urinalysis. Will add 1 prn visit tomorrow for assessment of signs and symptoms of exacerbating UTI.
S : Patient states she hasn’t taken meds.
O : Patient is hypotensive at 86/50. Pill planner indicates patient took BP medication at breakfast and lunch.
A: Patient appears to be unable to effectively manage personal medications as they are currently set up. Hypotension could be secondary to dehydration or overmedication. If medi-planner was set up correctly, patient likely overmedicated with her beta blockers.
P: Evaluate a timed dispensary for medication management and plan next visit with caregiver present during visit to review proper medication schedule.
S: Patient states “I didn’t even notice my legs were swollen until I tried to put my shoes on before you got here.”
O : Patient has 3+ edema with no signs of respiratory distress
A : Patient exhibiting early signs of heart failure exacerbation due to increased edema but no signs of respiratory distress. Patient not able to manage or recognize changes in lower extremity edema as a warning sign effectively.
P : Evaluate patient’s ability to verbally report signs of heart failure. Assess edema, lung sounds for signs and symptoms of heart failure.
S - "I'm not coughing anymore.”
0- Lungs with coarse breath sounds upper airways which cleared with cough and diaphragmatic breathing; coarse crackles to left lower lobe. Pt noted to be dyspneic with exertion on ambulation. Frequent dry, congested, non-productive cough. 2+ pitting edema to right lower extremity, 1+ edema left lower extremity without compression stockings or elevation of legs. Loss of balance when patient attempted to get out of chair. She fell backwards into chair and required assist of one to safely get up.
Increased swelling in legs, abdomen, hands, or face Shortness of breath at rest.
Education today with Mr. X focused on symptoms of profuse sweating and dizziness with LE swelling as these areas have been key issues with him. Patient able to verbalize these specific symptoms without cueing of early HF exacerbation and agreed to call the HH agency when/if these symptoms occur.
Example 2: Instruct on appropriate measures to prevent pressure and shear related skin problems.
Details/comments: Instructed patient on frequent position changes at least every 1 to 1.5 hours. Careful attention should be paid to protect bony prominences. Specifically, right, lateral hip is an area at risk for skin breakdown for patient due to tendencies to always sleep on right side due to wound on left side. Patient demonstrates ability to view this at-risk area using the mirror in their bathroom.
Instructed to limit chair sitting to 1 to 1.5 hours at any one time in order to facilitate improved lower extremity circulation and pressure relief
Instructed to encourage frequent ROM, movement, and/or activity to include ambulating around the home with his caregiver and walker at least 5 times per day in order to improve circulation. Caregiver agrees to write in the home log the number of times patient walked around the house for at least one week.
Example 3 : Instruct on the need to effectively manage urinary and/or fecal incontinence
Details/comments: Instructed that excessive moisture and/or urinary or fecal incontinence may lead to significant problems with skin integrity including breakdown and ulcers. Instructed in techniques to reduce risk to skin integrity related to urinary and/or fecal incontinence to include changing “Depends” undergarments 4 times per day to reduce redness and inflammation in the genitourinary area. Patient agreed to change undergarments on awakening, before lunch, before dinner and before bed and has placed 4 “Depends” on her bathroom counter next to her toilet as a reminder.
THERAPY EXAMPLES
ADD-ON PT
Therapy subjective "I just don't think I can do all this. It feels like too much."
Therapy assessment/plan:
Patient presents with noted decline since this therapist last saw her in the fall of last year. Motivation, depression appears to be a significant issue for her. She has marked decreased strength, decreased gait speed, tug time, and overall increased need for functional assistance. Patient has excellent family involvement and support: son and daughter-in-law present for evaluation today and report they are looking into several things: they have toured ALF and are seeking other SNF or ALFs; in addition they are seeking psychiatrists to assist with depression/anxiety and medication management for these issues that have been worse recently. They are also increasing the level of paid cg assistance in the home, tonight being the first of which
they will have overnight care. Patient will benefit from physical therapy services to increase functional mobility deficits and address impairments, provided that patient is cooperative and participatory in treatment sessions. Patient with negative thoughts on being able to recover from her recent functional decline.
Plan Plan to see patient 2wk4 for progressive gait training, ther-ex, balance/fall prevention to maximize her functional mobility in the home. Will incorporate caregivers into treatment visits to facilitate the carryover of benefits of interventions. Next visit will include introduction of the OTAGO exercise program.
ROUTINE PT
Therapy subjective
Patient states he had a very large BM this morning that resulted in the need for a shower. Otherwise he states he feels great.
Therapy assessment/plan Wheelchair propulsion and wheelchair transfers to chair in den is focus of mobility of late with noted difficulty advancing LE’s and maintaining forward progress during propulsion. Continued repetition and training have improved his overall transfer ability to minimal assist. This may become better, but would need stiff seating surface and the cushion to be elevated to be a more independent transfer. Patient still on track for discharge. Stomach pain associated with constipation is not a limiting factor with transfer ability today.
Therapy Plan: Follow up with daughter who is supposed to be purchasing a firmer cushion in order to advance with transfer ability. If daughter is unable or unwilling to purchase cushion, proceed with plans to discharge patient for reaching maximum potential with all goals.
INTERVENTIONS
The Pre-populated details in Point Care should be viewed as “prompts” for elaboration of the specific treatment and should include patient/CG response that occurred on the visit. Details that are not pertinent to your patient should be edited out. Added text by the clinician to clarify the patient specific response, thereby supporting a skilled need, is highlighted.
Provide skilled assessment and basic instruction of appropriate pain management techniques. Instruct on:
details/comments: non-pharmacological pain control methods including rest and activity patterns, taking medications as prescribed while pain is still tolerable. Patient able to verbalize the need for taking pain meds before pain level reaches a “ 4 ” on the pain scale and agrees to rest 3
Initiated phase 1 of standing, supported OTAGO exercise to include ankle pumps and heel raises for 10 reps, repeated 2 times. Patient holds onto kitchen countertop with cues required for upright posture during each exercise. Patient to perform these exercise 3 times per week utilizing calendar in the fall prevention booklet to track progress and compliance. Patient able to find calendar in book and agrees to log exercise compliance each time performed.
ADD-ON SLP
Therapy Subjective
Patient’s daughter in law, who is very involved in her care, was present for evaluation. She reports that patient has had a steady decline and overall is more confused and has difficulty communicating. She states that she thinks patient has been hallucinating as she has made comments about her old cat being in her apartment. Daughter-in-law wishes that she would like for conversations with patient to come a little easier.
Therapy Assessment/Plan
Patient presents with neurological structural impairments related to dementia diagnosis. Based on patient presentation, daughter’s concern regarding hallucinations are more consistent with disorientation. These structural impairments result in functional impairments of cognition including memory, attention, orientation as well as voice and speech functioning for communication as evidenced by 6/30 on MOCA assessment and patient only 55% accurate for word finding and confrontation naming. These functional impairments prevent patient from communicating in all needed and desire settings and with management of health conditions, completing ADL/IADL tasks with independence, participating in routine community and life activities including conversation and participation in social and group settings, which further impacts recreation and leisure activities as patient likes to play bridge with other residents and "chat" afterwards. These results indicate severe cognitive decline and issues with executive functioning, naming and language, recall, and attention. Potential barriers to improvement include overall level of cognitive decline and need for assistance/prompting to use word finding strategies and complete all executive functioning tasks.
Plan:
These deficits require skilled intervention to provide further cognitive assessment to determine best ability to function and intervene for improved verbal expression. Based on ST eval, skilled intervention by SLP services is recommended 2w4 targeting aforementioned needs with immediate focus on teaching caregivers appropriate strategies for effective communication and distraction.
ROUTINE VISIT SLP
ST
Therapy subjective
Patient reports that she had a follow up appointment with her surgeon that operated on her elbow today and that she can stop taking her antibiotics after today when she is out. Patient reported that she needs to come back to that md in 3 weeks and that blood was drawn today.
Therapy assessment/plan
Patient was very receptive to new med system and demonstrated good awareness of what she is taking and how to adapt to new system. Patient agreeable to start taking meds from med boxes
tomorrow. "Cheat sheet" that she says has been helpful was placed with med boxes for better recall and increased comfort. Therapy plan : Verify accuracy with medication management with the new system on next visit and begin treatment on strategies to recall information.
INTERVENTIONS
The Pre-populated details in Point Care should be viewed as “prompts” for elaboration of the specific treatment and should include patient/CG response that occurred on the visit. Added text by the clinician to clarify the patient specific response, thereby supporting a skilled need, is highlighted.
SLP Example #1 :
Indicate skilled therapy treatment this visit:
Details/comments: Patient was administered the montreal cogntive assessment to assess cognitive- linguistic and executive functioning skills. Patient scored a 6/30 (26/30 considered to be normal) which represents an approximate 99% impairment level. Specific subset scores as follows:
-visuospatial/executive functioning: 1/
-naming: 2/ -attention: 2/
-language: 0/
-abstraction: 1/
-memory/delayed recall: 0/ -orientation: 0/
SLP directed informal structured assessment word finding and language skills. Patient was shown pictures of common household objects and asked to name them in confrontation-style task. Patient was able to name 11/20 word but for those unable to name, did show some ability to use gestures and cued descriptions to express herself. Patient showed same approximate accuracy with ability to state the function of each object. Patient was then shown action pictures and asked to use short phrases to express each activity. Patient was able to describe for 13/20 action pictures. Descriptions lacked some content words but patient again showed ability to circumlocution and gestures use to express.
SLP Example 2: Instruct patient/caregiver on the use of medications to treat disease processes
Details/comments: Patient has multiple single row med planners, each of which had some assortment of medications in them. SLP directed structured organization and sequencing task targeting improvement in accuracy and independence of medication planner filling and med
Increased pain in pelvis affecting functional ability & activity tolerance. Increased confusion noted today with dx of UTI at ER visit yesterday. Therapy plan :
Bathroom mobility next visit with emphasis on safety with shower transfers
INTERVENTIONS FOR OT
The Pre-populated details in Point Care should be viewed as “prompts” for elaboration of the specific treatment and should include patient/CG response that occurred on the visit. Added text by the clinician to clarify the treatment and patient specific response, thereby supporting a skilled need, is highlighted.
Instruct on environmental safety issues to resolve immediate safety threats.
Details/comments: home falls & accidents screening tool identified 9 hazards associated with mobility, flooring, lighting, & bathroom; recommendations for keeping pathways clear, keep nightlight on, wear non-slip socks / shoes at all times, consider obtaining tub bench & lhs (resources given), have assistance with all transfers, consider installing grab bars in tub / shower area, consider obtaining walker skis or remove rugs, and reviewed spine precautions. Client/daughter understanding of these measures is good and daughter agrees to address patient footwear and lighting at night initially to reduce risk of falling related to environmental concerns.
Provide skilled assessment and basic instruction of appropriate pain management techniques. Instruct on:
details/comments: educated on proper utilization of pain scale including use of pharmacological and non-pharmacological methods to control pain levels between 4 and 6. Instructed patient in importance of edema management and rest 2-3 times per day in supine position before pain level reaches a “ 4 ” and before noticing edema in lower extremities. Patient agrees with this plan and appropriately demonstrates supine, resting position and verbalizes appropriate signs and symptoms that will warrant a call to the home health agency.
