Initial History and SOAP Note

TAs – Bench to Bedside

 Outline
1. Format of the initial history

2. Dos and Don'ts 

3. SOAP Note

4. Additional information about surgical note writing

 Initial History
Settings? 

• ER, Ward Day 1, Pre-op ward admissions, clinics, when you are
on call 

Where to document?

• Progress note in wards

• Consultation sheet in clinics
• Specialty specific forms : chc, endo, obgyn, psych 
Components
• Demographics
• 23-year-old, female, no comorbid conditions etc.  
• Presenting Complaint (PC) and duration 
• HOPC : ask open ended questions 
• SOCRATES for pain
• OCDPFAAA for non-pain chief complaint 
• Onset, Constant, Duration, Progression, Frequency, Alleviating
factors, Aggravating factors, Associated symptoms
While mnemonics are helpful to make sure no important information is missed
out, history taking is not an exercise in record keeping, think about the presenting
complaint and ask pertinent questions that can lead you to the diagnosis
• Review of Symptoms (important positives and negatives): again, think
about the presenting complaint and ask relevant questions. Ask
menstrual history from females
• PM/PS/Transfusion Hx
• Personal Hx: addictions, allergies 
• Medications 
• often difficult to obtain, but try to get as much information as possible from
patients (dose, duration, frequency, route etc.)
• Try to write generic names instead of brand names 
• Use the Pharmapedia Pakistan or similar apps to search generic/brand names 
• Physical Exam : General physical and system specific depending on the
complaint
• General examination: Pt. lying comfortably + any positive findings
• Chest/CVS: (Breath sounds, wound clean/unclean, etc.)
• Abdomen: (Gut sounds. Firm/soft, tender/non-tender wound clean/unclean, DRE and
Genital Exam if indicated etc.)
• Extremities: (DVT socks, edema, cannula sites for phlebitis etc.)
• Vascular and CNS and Breast exams may be indicated in certain situations

• VLE has videos on all these examinations by AKU faculty 

• Course: Clinical Videos Year III (aku.edu)
Visual Representation
of the exam findings
Fishbone
diagrams
•mention important/recent
ones
•clearly document if done
outside AKU or on a different
MR number)
Assessment/Plan
• Briefly describe the salient features/summary of the case so far : what
you think is going on and what you plan to do for the patient 
• Provide a list of differential diagnosis based on the presenting complaint
• Make a problem list (admitted patients) 
• the reason for admission, chronic conditions and any problems that arose during
the admission/hospital stay 
• Give your recommendations for each problem
• For e.g., if you are suspecting infection in a febrile patient, mention the workup
and medications 
• You are not expected to know the exact dose or duration 
 Dos and Don'ts
Use Only use the official progress note 

Mention Mention your name and M#

Confirm Confirm the name and MR# of the patient or use the barcode sticker 

Use Only use JCIA approved standard abbreviations

SOAP Note
Day 2 onwards in wards till discharge
Pattern:
• Date/Time
• POD#, Diagnosis, Procedure: 34 yr. old, male, diagnosed with
pancreatic cancer, S/P Whipple's procedure, POD 2
• Subjective: 
• Summary of significant events during the last 24 hours 
• Include assessment of pain/diet/bowel function/activity level/other
symptoms if any
• Objective 
• Vitals 
• Temp: Max temp + time of max temp
• HR: lowest-highest range
• BP: Systolic range/Diastolic range
• RR: lowest-highest range (mention if on oxygen/RA)
• Sats: lowest-highest range
• Input/Output : urine, drains, stoma
• Comment on the color of the fluid in the drains
• General Physical, Chest, Abdomen, Legs (DVT), Cannula sites, Other systems if
indicated 
• Incisions/Wounds if indicated
• Investigations 
• Labs, radiology, others 
• Problem List, Assessment and Plan 
Surgical Rotations
• The day after the surgery, you may be asked what happened in the
surgery, include main details in the SOAP note
• Post op history should focus on: 
• Flatus/vomiting/diarrhea/constipation/Chest Physio/Spirometry
• Post op fever is a common occurrence and has specific causes depending on
the POD
The five W's of Post OP fever
Assessment and Plan
• Assessment: Patient is stable/unstable/improving/deteriorating, include major issues 
• Plan:   
• Any labs/medications you would like to order based on the assessment 
• Things that are monitored after most surgeries include:
• Diet: soft/liquid/regular/diabetic
• Feces/flatus/constipation/diarrhea/vomiting
• Drain management: remove/monitor
• Chest physio: why is it important? Atelectasis after surgery
• Mobility: to avoid DVT
• Wound care: frequency and type of dressing
• Antibiotics:
• Pain:
• Discharge plans: (if any)
 Patient's name and MR# 
Clearly mention the
date and time
Alternatively use a barcode
sticker
Underline MEDICAL
STUDENT NOTE

Sample
SOAP Name, Signature

note and M #
Cultural sensitivity
• Consent: Always ask, never assume! 
• Be professional, courteous and explain the procedure in simple terms in Urdu 
• Do not automatically assume that the consent will be denied for breast/genital exams
• Mention purpose, exposure, overview of steps, anticipated pain/discomfort etc. 
• Privacy
• Beds in the general ward and ER are separated by curtains
• Exposure
• For an abdominal exam, is exposure from nipple to mid-thigh appropriate culturally?
• Chaperone
• Can family members be chaperones? 
• Same gender as the patient 
• Language Barrier 
• Use simple Urdu words, avoid switching to English unless understood well by the patient. 
• Do not use medical jargon with any patient. For e.g., say kidney function test instead
of BUN/Creatinine 
• If a translator is required, utilize the services of the hospital's official translator instead
of family members where possible
• List of commonly used medical terms and their Urdu translations will be uploaded on VLE
soon
• Confidentiality
• Discussing patients with colleagues not involved in patient care or with the team
outside of patient care areas, and leaving patient notes in the seminar rooms is highly
unprofessional and unethical
Highly Recommend watching these videos by Dr. Eric Strong: 
1. The Medical H and P (Part 1 of 2) - YouTube
2. The Medical H and P (Part 2 of 2) - YouTube
3. The Medical H and P (Comparative Examples) - YouTube

Book Recommendations: Bates' Guide or Macleod's

Questions?