How to Document on Ward Rounds Using the SOAP Framework.
Introduction
Medical students who are soon to be interns need to acquire the skills of clerking on ward rounds. The SOAP framework (Subjective, Objective, Assessment, Plan) enables proficient and easy documentation on ward rounds and provides the basics required for good documentation.
One can use many different methods, such as SOAP or DAVID & WENDY, as long as you are comfortable and efficient with your documentation system. Documenting should be written in a simple manner that anyone can easily follow. Everybody will document differently from person to person and from rotation to rotation; hence, tailoring your documentation appropriately is essential. When reading other colleagues' notes, notice what makes sense, what was made well or poorly, and learn from it. A hot tip is to save your framework on the computer through your logins so that you can apply it quickly during ward rounds. This is particularly useful as there isn't much time being spent with the patient in some rotations, such as surgery. Another tip is to practice writing without looking at the keyboard, a skill that I am severely lacking.
In general, SOAP helps understand why the patient is in hospital, what has significantly happened to them during admission, the management (investigations, bloods, scans and so on), and the general direction/progression. Do remember that you have to write with accuracy to appease the medicolegal gods as a surgeon once told me, "what is a surgeon in a full suit in Queensland? The defendant" (albeit maybe not due to inadequate documentation, but you get the idea).
Before you start
Whilst you are waiting for the consultant/boss to arrive, you may want to prepare your notes. In some establishments, a pre-ward round has already been done to familiarise the patients' ongoing management and how they are going (it also helps to present during ward rounds).
On each note:
Title your notes with a heading starting with the reason for seeing the patient (ward rounds, reviews and so on), the team involved and where the patient is situated. For example: WR (ward round) Team 1 G4 (ward G, 4th floor) -> WR Team 1 G4. It will, of course, look different as every hospital have its way of doing things.
Name and position of everybody on the team. It is primarily done in order of seniority.
Date and time, but that should be stamped by the computer when the note was made. Notes can be written retrospectively, such as "seen at 10 am written retrospectively”.
You can paste the day-to-day management if nothing has changed. However, don't be lazy and be careful with too much pasting, as many colleagues can tell. This may lead to patient negligence.
Use one/two-liner describing the name/age/presenting complaints/important things that happened. For example, 72-year-old female, on day 3 of admission with uncomplicated community-acquired pneumonia, is currently on day 3 of IV antibiotics.
SOAP - the four compulsory categories
Subjective
The subjective part looks at how the patient feels in their own words. This can be compared to how they felt from the last time the team reviewed them. Try to document as precisely as possible and use quotation marks to demonstrate patients' own words when quoting directly what they have said. You may write who was in the room at the time of the review, such as "Tom, the husband, was present in the room".
Ask about their chief complaints. Use SOCRATES if necessary.
You may ask if they have any pain (new, ongoing, changing), nausea, other symptoms and so on. Explore each concern.
In some instances, you may want to clarify the history of presenting illness, history (medical, surgical, family, social), system review, allergies and medications.
A typical early mistake is to mix symptoms and signs. Symptoms come from the patient's perception and how they are describing their concerns. For example, "I have stomach pain". Signs are objective findings related to the symptoms the patient mentions. For example, "abdominal tenderness on palpitation at the epigastric region".
Objective
The objective section is the scientific approach and gathering data from the patient. Pay attention to what you can see, smell, feel and hear.
Just like any examination, start with the general appearance of the patient. Are they distressed, pale, jaundiced, cachectic and so on?
Vitals should be recorded: the usual SpO2 saturation, pulse rate, blood pressure, respiration rate and temperature.
Fluid balance: what goes in/out? Are they on any restrictive fluids? What is the urine output? Notice any other drains.
Clinical examination findings. It is best to use shortcuts on the computer.
Cardio: HSDNM, regular pulse, good character and volume.
Resp: clear bilaterally, resonant, no other sounds.
GI: soft, non-tender, bowel sounds present.
Lower limbs: nil oedema, CRT less than 3 seconds.
Neuro (if appropriate).
Investigation results of bloods/images. Notice trending.
Assessment
The assessment contains the summary and impression of what is going on. It is vital to summarise the salient point that will lead to a primary diagnosis with possible top differentials. The impression should be written as a one-liner. For example: community-acquired pneumonia. Be careful with your impression as sometimes you may write down what is going on but has not yet been confirmed through investigations. Your consultant might say something if you insinuate a diagnosis before confirming. If the diagnosis is made and proven, you may want to describe how the patient is going. For example, is the patient clinically stable/improving on X/slow to progress/newly unwell/needs further investigations and so on.
Thus: summarise your assessment/salient points, and add your impression.
Plan
What is the plan for this patient? The plan needs to be concise and easy to understand as it addresses all the issues found and how to solve them. Document when tasks have been done and at what time.
The plan/tasks may include:
Further investigations: bloods/imaging.
Fluids/diet restrictions.
Oxygen required?
Medications: added, removed, changed dose/route/frequency/brand.
Frequency of observations.
Referrals.
Allied health involvement.
Next review.
Estimated date of discharge.
Other categories - there are plenty of others!
David & Wendy
Diet: what are they allowed to have.
Activity: are they resting in bed, can they weight bare, are they walking around? Is mobilisation/sitting being encouraged?
Vitals: normal/abnormal, need to clarify, trending?
Investigations: reviewing old ones/new ones, planning to order.
Drains and lines: cannulas, central lines, abdominal wound drains, chest tubes, catheters, PICC lines. Check and record output. Clean if needed and look for infections (cellulitis). Can they come out?
Wounds: especially in the surgical patient, check wounds/dressing and their progression.
Examinations: your typical examination where they must be focused.
Nursing concerns: team leaders can join you and raise concerns which is helpful as the whole team can be used. Problems get fixed faster.
Drugs (including antibiotics, insulin usage and VTE prophylaxis): review the medication chart every day. Are antibiotics still appropriate? Medication withheld/ceased?
Y can't they go home: are they unwell, still pending, social point of view such as nowhere to go.
Published 15th February 2022. Last reviewed 30th April 2022.
Reference
Catherine Moore. Writing SOAP Notes, Step-by-Step: Examples + Templates. Quenza website. https://quenza.com/blog/soap-note/. Updated April 13, 2021. Accessed: February 12, 2022.
Dr Lewis Potter. How to Document a Patient Assessment (SOAP). Geekymedics website. https://geekymedics.com/document-patient-assessment-soap/. Updated November 12, 2021. Accessed February 10, 2022.
Podder V, Lew V, Ghassemzadeh S. SOAP Notes. [Updated 2021 Sep 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482263/.