Basics for the Wards: How to Write a Surgery SOAP Note

For most internal medicine and related specialties the SOAP notes will be pretty in-depth. Now, forget most of that for your surgery rotation because they don’t care.

Introductory/summary line: age of patient, lady/gentleman, brief relevant history, post-op day (POD) what for what procedure (ex: 27 yo gentleman who was the unrestrained driver in a MVA and presented with a seatbelt sign and grade IV splenic lac. POD 5 ex lap and splenectomy).

Subjective: How is the patient feeling?
+/- pooped/passed gas/peed/gotten out of bed  (not pooping keeps people in the hospital for days and days)
+/- headache, chest pain, shortness of breath, nausea, vomiting, abdominal pain
Scale of 1 to 10 where is their pain, is it tolerable to them (complete eradication of pain is usually not feasible, but reducing it to a level when the patient can bear it is generally achievable).
What is their diet (NPO, clear liquids, soft, regular) and are they tolerating it

Objective: Vitals- my attendings preferred this order for the last 24 hours or so= temperature current, temperature max, blood pressure range, heart rate range, respiratory rate range, O2 sats range on room air/oxygen rate.

Ins and outs (I&O’s) last 24 hours in 8 hour intervals. My attendings don’t care so much about ins unless TPN is involved, but outs are very important- especially if there are multiple drains (chest tubes, JP, etc). List all drains separately, be sure to include if they are to gravity or suction or clamped, and note the appearance of whatever is draining. If it is just blood, call it sanguinous; if it is blood and fluid, call it serosanguinous; if it is just fluid, call it serous; and if it is black, call it bilious. You will probably get some brownie points if you use those terms right off the bat.

I was on trauma and elective surgery, so mostly they cared about the abdominal physical exam. However, if you are on cardiothoracic or orthopedic surgery, those folks will care more about their specialty. Do a brief complete physical exam every time because that is good patient care, but always be sure to spend a little more time on the area your particular service is most concerned about.
- Head: NCAT (normocephalic, atraumatic), or if their face is beat up, note swelling and/or cuts.
- Lungs: CTAB (clear to auscultation bilaterally), note any chest tubes and the things about them here
- Heart: RRR (regular rate, rhythm), tachycardic/bradycardic if relevant
- Abdomen: NTND (nontender nondistended) or ATTP (appropriately tender to palpation), listen for bowel sounds, note any incisions and drains and the things about them here.
- Extremities: moves all 4 spontaneously, note any cuts, casts, or external fixation devices here.

When you are talking about surgical incisions and dressings you always want them to be CDI (clean, dry, intact). But if the wound is not CDI, note what it looks like- is it erythematous (red), swollen, coming apart, draining anything and what that looks like. Sometimes it is not a good idea for you to undress a wound, in which case try to find whoever changed it or saw it last to see what it looked like, and report on what you saw of the dressing.

Report labs after the physical exam. I found that surgery, unlike internal medicine, will not order a daily CBC and CMP on everyone. That’s ok! Order labs that will help with the management of your patient- not everyone needs a full lab workup every morning.

If any specimens were sent to the lab, summarize any pathology reports or cultures. It is ok to note that a specimen was sent off and the result isn’t back yet.

Relevant imaging (ex: followup chest ray or CT scan).

Assessment: Summary statement again.

Plan: You will look like a rock star if you are actively trying to make plans for your patients. Your two goals are to improve patient care, and get them out of the hospital. So, if the patient is having trouble getting out of bed, consult PT/OT; can you de-escalate their pain medicine from IV to PO; can you advance their diet; what lines can you dc- foley, central, etc; do we need to consult anyone for subacute rehab or other discharge planning needs. The general discharge criteria are that the patient is on oral pain medicine, and can eat/drink/poop/pee/walk on their own. Obviously those are not applicable to every patient, but they are the general goals that indicate a patient is safe to leave the acute hospital setting.

There you have it! Good luck!

a few medical exam acronyms and meanings

GEN (general exam = how you look):
NAD (not in acute distress = you don’t look like you’re in need of immediate medical attention)

HEENT (head, eyes, ears, nose, throat):
NCAT (normocephalic atraumatic = non-injured normal-shaped head)
PERRLA (pupils equally round and reactive to light and accommodates = pupils are the same size, round, gets smaller with light and when looking towards the nose)
EOMI (extraocular movements intact = eyes can look in every direction)
MMM (moist mucous membranes = your eyes and mouth aren’t dry)

CV (cardiovascular = heart exam):
RRR (regular rate and rhythm = your heart is beating normally)
No MRG (no murmurs, rubs or gallops = no heart sounds other than BaDmp BaDmp)
No JVD (no jugular venous distention = the veins in the neck aren’t visibly pulsing)

PULM (pulmonary = lung exam):
NRE (normal respiratory effort = breathing easily)
CTAB (clear to auscultation bilaterally = both lungs sound clear)
No WRR (no wheezes, rales, or rhonchi = no weird breath sounds like whistling, crackles, or ripping velcro)

GI (gastrointestinal = belly exam):
No HSM (no hepatosplenomegaly = your liver and spleen don’t feel or sound large when I press on your belly or scratch at your tummy skin)
+BSx4/4 (positive bowel sounds in four out of four quadrants = I could hear tummy gurgling in four different spots around your belly button)

EXT (extremities = your arms and legs):
5/5 BL UE/LE (five out of five strength in bilateral upper extremities and lower extremities = great strength in both arms and legs)
4/5 (weak strength)
3/5 (can barely move limbs against gravity)
2/5 (too weak to lift against gravity but can maybe move from side to side)
1/5 (can’t move)
2+DPs (adequate distal pulses = I can easily feel the pulses in your wrist, the top of your feet, and behind your ankle bones)

NEURO (neurological exam = sensation, coordination, and reflexes):
CNII-XII intact (cranial nerves two through twelve are intact = your vision, eye movement, hearing, facial muscle strength, tongue and uvula movement, head and neck and shoulder movement and strength seem good)
3+DTRs (adequate deep tendon reflex response = I can feel your muscles tense appropriately when I hit the outside or inside of your elbow, your forearm, your knee, or the back of your heel)

PSYCH (psychiatric exam = level of alertness, orientation, concentration, memory, and mood)
AAOx4/4 (alert and oriented to person, place, time/date, and situation = you’re awake, you know who you are, where you are, the date, and why you are where you are right now)
NMA (normal mood and affect = you aren’t inexplicably angry or sad and your facial expression appropriately reflects your mood)