Pre Op SOAP Note: A Comprehensive Guide
Understanding the pre-operative SOAP note is crucial for healthcare professionals and patients alike. SOAP notes, which stand for Subjective, Objective, Assessment, and Plan, are a fundamental tool in medical documentation. This article will delve into the intricacies of a pre-operative SOAP note, providing a detailed and multi-dimensional overview.
Subjective
The subjective section of a pre-operative SOAP note captures the patient’s history and concerns. It includes the patient’s chief complaint, history of present illness, and any relevant past medical, surgical, family, and social history. For instance:
| Subjective | Details |
|---|---|
| Chief Complaint | Pain in the left knee for the past 6 months |
| History of Present Illness | Patient reports gradual onset of pain, worsening with activity and at night |
| Past Medical History | Diabetes mellitus type 2, hypertension, and hyperlipidemia |
| Family History | Parental history of osteoarthritis |
| Social History | Smoker for 20 years, currently quit for 6 months |
Objective
The objective section of a pre-operative SOAP note details the physical examination findings. This includes vital signs, head-to-toe assessment, and any specific findings related to the patient’s chief complaint. For example:
| Objective | Details |
|---|---|
| Vital Signs | BP: 130/80 mmHg, HR: 80 bpm, RR: 16 bpm, Temp: 37.0掳C |
| General Appearance | Well-nourished, no jaundice, no cyanosis |
| Neck | No lymphadenopathy, no thyromegaly |
| Heart | No murmurs, rubs, or gallops |
| Lungs | No wheezes, rales, or rhonchi |
| Abdomen | Soft, non-tender, no masses |
| Extremities | Left knee shows swelling, effusion, and limited range of motion |
Assessment
The assessment section of a pre-operative SOAP note summarizes the findings from the subjective and objective sections. It includes a differential diagnosis and the patient’s risk factors. For example:
Assessment: Left knee pain, likely due to osteoarthritis. Risk factors include family history, smoking, and diabetes mellitus type 2.
Plan
The plan section of a pre-operative SOAP note outlines the intended management and follow-up. This includes pre-operative tests, procedures, and post-operative care. For example:
Plan:
- Order pre-operative blood work, including complete blood count, electrolytes, and coagulation studies
- Order chest X-ray to assess for pulmonary function
- Administer pre-operative antibiotics 1 hour prior to surgery
- Perform pre-operative patient education on post-operative care, including pain management, wound care, and activity restrictions
- Arrange for post-operative physical therapy and follow-up appointments
Understanding the pre-operative SOAP note is essential for ensuring a smooth and successful surgical process. By carefully documenting the patient’s history, examination findings, and management plan, healthcare professionals can provide the best possible care for their patients.