SOAP

To earn full credit, the student must do the following

Length

5-6 pages, not including title page or reference list

Spelling/grammar

APA

Little to no errors in spelling, grammar, or APA formatting

Timeliness

Submitted on or before the assigned due date

Background information & History of Present Illness

Described how the patient arrived, what facility the patient is being seen in, the patient’s chief complaint, age and gender.

Smoking history in pack years, presence of pulmonary disease, height, weight, IBW, work history or environmental exposure, home oxygen, home medication list, comorbidities

Subjective information

Patient or family member responses to practitioner interview

Objective Information

Results of physical assessment, vital signs (HR, RR, Temp, Sp02, BP), equipment settings, diagnostic testing. Be sure to include sputum characteristics/culture, CXR or CT results, breath sounds, ABG, lab data, ECG, mental status, PFT, ventilator/Bipap settings, inspection, percussion, palpation, hemodynamic measurements

Assessment/

professional judgment

Provide possible explanations or interpretations for each abnormal piece of data collected based on evidence-based practice

Plan of action

Provide both the physician’s plan as well as your recommendations for the continued care of this patient; provide rationale as appropriate. Include any relevant therapeutic objectives you wish to obtain.

Accuracy and completeness of information

All information should be factual, calculations should be correct, and a thorough description of all medications, conditions, should be included.