NURS 6521 SOAP Note for Hypothyroidism

What is a SOAP Note

A SOAP note is a documentation format used by healthcare providers to document the subjective, objective, assessment, and plan for patients in their medical records. The acronym “SOAP” stands for:

  • S: Subjective information, which includes the patient’s symptoms, feelings, and concerns as reported by the patient or caregiver.
  • O: Objective information, which includes the results of the physical examination, laboratory tests, and any other measurable data.
  • A: Assessment, which is the healthcare provider’s interpretation of the subjective and objective data and the diagnosis or clinical impression.
  • P: Plan, which is the course of action that the healthcare provider will take to manage the patient’s condition, including treatment options, medications, follow-up appointments, and other recommendations.

How to write a SOAP Note

When writing a SOAP note, healthcare providers should include all relevant information about the patient’s condition and management plan. It is important to write in clear and concise language, using medical terminology when appropriate. Documentation should be legible, accurate, and complete to ensure continuity of care and facilitate communication among healthcare providers.

SOAP Note for hypothyroidism

Here is an example of a SOAP note for a patient with hypothyroidism:

S: The patient, a 35-year-old female, presents with complaints of fatigue, weight gain, and hair loss for the past six months. She also reports feeling cold all the time and having constipation. She denies any chest pain, palpitations, or shortness of breath.

O: On examination, the patient appears fatigued and has dry skin. Her vital signs are within normal limits. The thyroid gland is palpable and enlarged. There is no palpable nodularity. Laboratory investigations reveal a low TSH level and low free T4 level.

A: The patient is diagnosed with hypothyroidism, most likely due to autoimmune thyroiditis.

P: The patient is prescribed levothyroxine, 50 mcg daily, to be taken in the morning on an empty stomach. Follow-up thyroid function tests will be done in 6 weeks to assess the response to therapy. The patient is advised to maintain a healthy diet and exercise regularly to help manage weight gain. She is also advised to monitor for any signs of hyperthyroidism, including palpitations, sweating, and weight loss.