Discharge SOAP Note Example

Below is a nursing SOAP note for a discharge summary based on a case study, incorporating all applicable components and subcomponents, and utilizing the OLDCART acronym in the History of Present Illness (HPI) section:

Review: Other Nursing SOAP Notes Examples

• Psychiatric SOAP Note Example
• HEENT SOAP Note Example
• Respiratory SOAP Note Example
• Cardiovascular SOAP Note Example
• Abdominal SOAP Note Example
• Musculoskeletal SOAP Note Example
• Neurological SOAP Note Example
• Skin, Hair, and Nails SOAP Note Example

Subjective:

1. Chief Complaint: Patient is being discharged following treatment for community-acquired pneumonia.
2. HPI (History of Present Illness):
   • Onset: The patient was admitted to the hospital five days ago with symptoms of cough, fever, and shortness of breath.
   • Location: The patient reported experiencing respiratory symptoms throughout the chest and associated fatigue.
   • Duration: The symptoms had been present for approximately one week prior to admission.
   • Character: The patient described the cough as productive, with yellowish sputum. The fever ranged from 38.5°C to 39.2°C.
   • Aggravating Factors: The symptoms worsened with physical exertion, deep breathing, and lying flat.
   • Relieving Factors: The patient reported some relief with prescribed antibiotics and respiratory treatments administered during the hospital stay.
   • Treatment/Interventions Tried: The patient received intravenous antibiotics, supplemental oxygen, nebulization treatments, and hydration therapy during the hospital stay.
3. Past Medical History: Document any relevant past medical conditions, surgical procedures, or chronic respiratory illnesses that may be related to the current illness. Include details about any previous pneumonia episodes or chronic lung conditions.
4. Allergy History: Inquire about any known allergies to medications or substances encountered during the hospital stay. Note the type of reaction experienced and any known allergens to avoid.
5. Medication History: Record the patient’s current and past medication history, including the antibiotics, bronchodilators, and any other medications prescribed during the hospital stay.
6. Social History: Explore the patient’s living situation, including the availability of support at home, ability to access follow-up care, and any lifestyle factors that may affect recovery.
7. Review of Systems: Conduct a brief review of systems, focusing on symptoms related to the respiratory system. Inquire about associated symptoms such as chest pain, cough, sputum production, shortness of breath, or fatigue.

Objective:

1. General Appearance: The patient appears comfortable and in no acute distress.
2. Vital Signs: Blood pressure: 120/80 mmHg, Heart rate: 80 bpm, Respiratory rate: 16 breaths per minute, Temperature: 37°C.
3. Physical Examination: Lungs are clear to auscultation bilaterally, no signs of respiratory distress, no additional abnormal findings.

Assessment:

1. Medical Diagnosis: Community-acquired pneumonia.
2. Problem Identification: Patient presented with respiratory symptoms, including cough, fever, and shortness of breath.
3. Relevant Findings and Abnormalities: Productive cough with yellowish sputum, fever, and radiographic evidence of lung infiltrates consistent with pneumonia.
4. Client Education Needs: Patient requires education on medication adherence, respiratory hygiene, symptom monitoring, and follow-up care instructions.

Plan:

1. Medical Interventions:
   • Prescribe oral antibiotics to complete the course of treatment.
   • Provide prescriptions for symptomatic relief, such as bronchodilators or expectorants, if necessary.
   • Discuss the importance of completing the prescribed medications and scheduling follow-up appointments.
2. Patient Education:
   • Educate the patient on respiratory hygiene practices, including proper coughing and handwashing techniques.
   • Provide instructions on monitoring symptoms, such as fever, cough, sputum production, and shortness of breath.
   • Discuss the importance of adequate rest, hydration, and gradual return to normal activities.
3. Referrals or Consultations:
   • Schedule a follow-up appointment with the primary care physician or pulmonologist within one week for a post-discharge evaluation.
   • Refer the patient to a respiratory therapist or home healthcare agency for further assistance if needed.
4. Safety Measures:
   • Review any necessary safety precautions related to medication administration or potential side effects.
   • Provide information on when to seek immediate medical attention for worsening respiratory symptoms or signs of complications.
5. Evaluation:
   • Ensure the patient understands the importance of follow-up care and adherence to the prescribed treatment plan.
   • Encourage the patient to contact the healthcare provider if there are any concerns or persistent symptoms.

• This example demonstrates a discharge SOAP note based on a case study, incorporating all applicable components and subcomponents.
• The subjective section captures the patient’s chief complaint and provides a detailed HPI using the OLDCART acronym.
• The objective section includes general appearance, vital signs, and physical examination findings.
• The assessment section includes the medical diagnosis, relevant findings, and problem identification.
• The plan outlines the medical interventions, patient education, referrals or consultations, safety measures, and a plan for evaluation.