SAMPLE SOAP NOTE
S: Subjective—ask the patient how she is feeling today. Is she eating (liquids or regular)? Is she
ambulating? If her foley has been d/c’d, is she urinating? Has she passed any flatus or had a
BM? How is her pain? How is her lochia (more or less than a period)?
Always remember to ask about: nausea, vomiting, headache, visual changes, RUQ pain,
incisional pain, calf pain.
O: Objective—vital signs are found in the back of the chart. For blood pressure, I want the range
(lowest to highest for both systolic and diastolic), and for temperature I want BOTH the max
and the current temperature. Others you can just put the most recent, unless there are huge
fluctuations, in which case I would like a range. Don’t forget UOP.
GEN: alert, sleepy, comfortable, uncomfortable, etc.
CV: many pregnant and recently delivered won have a benign systolic murmur. Listen for
it! An S3 is not normal.
RESP: make sure there are no crackles or signs of pulmonary edema (e.g. JVL)
ABD: inspect the incision. You should remove the bandage and just recover the incision with
a pad unless their surgery was just a few hours ago. Do not remove staples unless
instructed and supervised. Look for redness around the incision, induration,
fluctuance, purulence. Also check for bowel sounds and the height/firmness of the
EXT: always check for edema, cords, homan’s.
A: Assessment—should always go something like:
26yo G3 now P3 Hispanic female s/p C-section POD#1 (3:00pm)
Always check the TIME and TIME of surgery, because the time may indicate whether or not we
can discharge them that day.
P: Plan—be organized and complete!
1. Pre/post op H&H
2. Chorio—on abx (list them), day # (of abx), and amt of time since last febrile temp, e.g.
Chorio on amp/gent/flagyl day #2, afebrile x 12 hours.
3. CLINIC (where they got their antenatal care) and preferred form of birth control (BTL,
pills, depo, IUD, or condoms)
4. Routine post-op care (you do not need to write “d/c Foley” or an: 4hing-it is automatic)