What is a SOAP Note?

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:

Subjective (S):

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.

Objective (O):

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).

Assessment (A):

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

Examples:

·         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.

Plan (P):

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.

S: Specific

M: Measurable

A: Attainable

R: Realistic/Relevant

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.

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Cancer of the Sigmoid Colon

The sigmoid colon is the terminal section of your large intestines that attaches to the rectum and anus — a sigmoid colectomy is a surgical procedure in which the sigmoid colon is resected. During this procedure, the sigmoid colon is removed and the remaining large intestine is then reattached to the rectum. After the procedure, patients will need to eat certain foods to allow the intestines to heal, as well as to prevent gastrointestinal upset such as diarrhea, constipation and excessive gas.

Patients should follow a low-fiber diet for about six weeks after discharged from the hospital. A low-fiber diet is imperative for post-colectomy patients to decrease the risk of trauma to the intestines and promote healing. After six weeks, slowly introduce fiber back into your diet. Patients can then increase fiber intake by only one serving each day, until they are able to tolerate 20 grams to 35 grams per day, or about five servings. Patients should be sure to drink plenty of water while increasing your fiber. Fiber can be constipating when not complemented with adequate water.

I recently led a follow-up appointment with a patient who was on his third chemotherapy treatment and recovering from a sigmoid colectomy. The patient consistently lost 14 pounds over the last 6 months but gained 10 pounds since his last appointment, which was last month. But, the patient reported that he was slowly gaining his appetite back but could not tolerate smells like he used to. On the SOAP (subjective, objective, assessment, plan) note I developed, I indicated that I educated the patient on the importance of keeping his weight up and maintaining that weight as well. It’s important for patients to maintain their weight after major surgeries like a sigmoid colectomy, in addition to cancer treatment. The stronger the state that the body is in, the more tolerable it will be towards the treatment of cancer. The patient is currently prescribed a vanilla-flavored supplement from the facility and reported that he couldn’t tolerate the taste of it sometimes. So, I educated him on different ways to make his supplement taste better like adding chopped strawberries to his supplement. We talked about what foods he could eat and how we were going to make sure that the patient listens to his body. By listening to his body, I mean if a patient can tolerate a certain food on a Monday- then eat it. But if he can’t tolerate that same food on Tuesday- try something different. The patient reported that he “forces himself to eat”, which is good for patients going through chemotherapy. A number of patients that are going through chemotherapy become easily frustrated. But, RDs are there to remind them that they need to fight through the frustration and aggravation of their senses (taste and smell specifically) changing.

Livestrong

This is an image of a normal colon

This is an image of a normal colon

This is an image before a sigmoid colectomy and highlights the area that will be removed.

This is an image before a sigmoid colectomy and highlights the area that will be removed.

This is an image of how the colon looks after surgery and the shows the section where surgeons re-connected.

This is an image of how the colon looks after surgery and shows the section where surgeons re-connected.