1. Nutritional Progress Notes

2. Objectives After this presentation, you will be able to:
State the descriptive words for the acronym SOAP
Give a brief description of the meaning for each word in the acronym SOAP
Write a progress SOAP progress note from a case study

3. What is a SOAP Note? S = subjective O = objective A = assessment
Summary report of client’s/patent’s condition
Written in client’s/patient's chart
Acronym for
S = subjective
O = objective
A = assessment
P = plan

4. Pros and Cons of SOAP Charting
Common use by nutrition care professionals and other medical disciplines
Taught in most dietetics education programs
Easy to learn and utilize
CONS
Can encourage lengthy chart notes
Some physicians are less likely to respond to this format than others
Can downplay continued reevaluation of client’s progress
Emphasizes legitimacy of objective over subjective data

5. S: Subjective
Information provided/spoken by patient, family, or other person.
Pertinent socioeconomic, cultural info
Level of physical activity
Significant nutritional history: usual eating pattern, cooking, dining out
Work schedule

6. Factual and reproducible observations.
O: Objective
Factual and reproducible observations.
Diagnosis
Height, age, weight—and weight gain/loss patterns
Lab data
Clinical data (nausea, diarrhea)
Diet order
Medications
Estimation of nutritional needs

7. A: Assessment
Summary of dietitian's professional nutrition diagnosis or clinical thoughts.
Interpretation of patient’s status based on subjective and objective info
Evaluation of nutritional history
Assessment of laboratory data and medications
Assessment of diet order
Assessment of patient’s comprehension and motivation

8. P: Plan
Describes the scope of Treatment and contains the action plan and prognosis.
Diagnostic studies needed
Further lab work or lab data needed
Medical nutrition therapy goals
Education nutrition plans
Recommendations for nutritional care
Date for any follow-up

9. Sample SOAP Note
Subjective S: works second shift, eats two meals a day, before/after shift; usually eats in fast food restaurants (fried foods, burgers, ice cream) for lunch and dinner. Does not add salt to foods. Takes blood pressure 2x/day. Activity: Plays volley ball on weekends

10. Sample SOAP Note
Objective O: 34 y.o. female; last menstrual period = 01/05/2006; iron level= 12.3; history of hypertension x 2 years; blood pressure = 130/85 for last four readings; height = 5ft. 3in; weight: 205 lb; BMI=36.

11. Sample SOAP Note Assessment
A: obese; hemoglobin level normal; excessive sodium intake (NI ) related to frequent use of fast food meals as evidenced by diet history. Blood pressure high/normal. Low physical activity.

12. Sample SOAP Note
Plan P: Reviewed DASH diet. Identified foods to pack from home to eat during lunch/dinner. Discussed non-food rewards to purchase with money saved from not eating out when weight and B/P goals are reached. Encouraged more activity to facilitate weight loss. Next appointment = 30 days from today.

13. Conclusion Not all the parts are used at every visit
Complete sentences are not necessary
Signature goes at end of last line
Never leave a blank line between entries
Never leave a half filled line. Draw a line to fill the line.

14. Lecture Quiz
What does the acronym SOAP stand for and give a brief description of the meaning for each word.
What medical professionals usually use SOAP notes?
Name one advantage and one disadvantage to using SOAP progress notes.

15. Lecture Quiz
Write a progress SOAP progress note using the following case study:
Your second appointment for the day is with a 25 year old Chinese male. He states he was told by his doctor that his cholesterol is high and he should to “eat better” but he is confused as to how to do that. He hands you a paper with the following labs on it: height = 67”; weight = 200#; blood pressure = 120/80; total cholesterol = 150 and LDL levels= 160.