A SOAP note is a form of documentation used by healthcare professionals to record a patient’s visit or consultation. It is an ongoing system to support the steps of the Nutrition Care Process (NCP) in the capacity of a hospital, long-term care facility, and other similar agencies. Standardized language is part of NCP, which improves both written and oral communication among members of the health care team as well as communication with the patient. A Registered Dietitian at my rotations said to me the first week I was there, “Ninety percent of life is communication.” And when the RD said this to me, it really stuck with me. Life really is based on communication- every aspect of it. So, if healthcare professionals all use the same words, or standardized language, when documenting the progress of a patient, it prevents a barrier of communication or confusion. These SOAP notes are designed to be relevant, accurate, and timely. Yes, there are several other forms of documentation but, the SOAP note seems to be the most commonly used. Here is a brief outline of how a SOAP note should be constructed:
This is where the healthcare provider enters all patient information or data collected from the patient or caregiver. This information would also include a diet recall and any food allergies that the patient reports.
This section is based more on physical evidence about the patient. Information in this section would include height, weight, BMI, weight change over a period of time, labs, PMH, medications currently using, or any other trending values (i.e.: TG levels over the past 6 months).
This is where the Nutrition Diagnosis is made. This diagnosis is referred to by healthcare professionals with a nutrition background, as a PES statement. PES stands for problem, etiology, and signs and symptoms. The PES statement is phrased as follows:
Problem related to etiology as evidenced by signs and symptoms
· Altered GI function related to Partial Bowel Obstruction/ileus as evidenced by hypoalbuminemia, parenteral nutrition.
· Excessive intake of simple sugars related to consumption of regular sodas and juices as evidenced by food and blood glucose logs.
· Inadequate oral food/beverage intake related to decreased appetite due to cancer and treatment as evidenced by dietary recall and unintentional weight loss.
This is the section where an outline of interventions is made necessary to treat the nutrition problems(s). Goals are made, short-term and long-term, using the SMART format.
T: Timely Manner
This section also includes information as to how the patient plans on monitoring their progress, when their follow-up consultation should take place, and if any multivitamins are being suggested.