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Soap Notes Guidelines

SOAP Notes are used in MOWINS for high-risk participants to document nutritional assessments. The SOAP format includes 4 sections: Subjective, Objective, Assessment, and Plan. The Subjective section includes statements from the patient on symptoms, feelings, and progress. The Objective section documents information like lab results, clinical observations, medications, and education. The Assessment section provides an interpretation of needs, diet/weight history, nutrient inadequacies, and expected changes. The Plan section outlines recommendations and goals for gathering more information, referrals, diet changes, supplements, monitoring, instructions, and follow-up visits.

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4K views1 page

Soap Notes Guidelines

SOAP Notes are used in MOWINS for high-risk participants to document nutritional assessments. The SOAP format includes 4 sections: Subjective, Objective, Assessment, and Plan. The Subjective section includes statements from the patient on symptoms, feelings, and progress. The Objective section documents information like lab results, clinical observations, medications, and education. The Assessment section provides an interpretation of needs, diet/weight history, nutrient inadequacies, and expected changes. The Plan section outlines recommendations and goals for gathering more information, referrals, diet changes, supplements, monitoring, instructions, and follow-up visits.

Uploaded by

Mcjeauvy Comaad
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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SOAP Guidelines

SOAP Notes are used in MOWINS for high-risk participants. Standard Abbreviations list is
available in the Health and Nutrition Assessment Handbook (HNAH), located in the WOM.

Start Note by: MOWINS will capture this


Date & Time: MOWINS will capture this

1. Patient, significant other, family, or staff tells the professional


2. Can include symptoms, feelings, history, and progress
3. May be in format of ‘patient reports…’ or given as a direct quote, as, “I don’t have any appetite at
all today.”
Subject 4. THESE STATEMENTS ARE CHOSEN TO ILLUSTRATE A POINT MADE IN THE
ASSESSMENT
5. No more than 1 or 2 well-chosen statements necessary

1. SPECIAL DIET:
2. ANTHROPOMETRIC DATA: (Height, weight, IBW, % IBW, % usual weight, TSF percentile
and/or % std, AMC percentile and/or % std)
3. LAB RESULTS: (1/21 Albumin 3.5, Total Lymphocyte County 1367, etc)
Objective 4. CLINICAL OBSERVATIONS RELATING TO NUTRITIONAL ASSESSMENT: (+ or – edema,
emaciation, decubitous ulcer)
5. DIET: [Nutrition Assessment revealed]
6. MEDICATIONS: (Note the ones SPECIFICALLY relevant to nutritional status)
7. REPORT OF EDUCATION: (Instructed pt on ____ diet; Materials given ….)

Interpretation of
1. Caloric needs for …(weight loss, breastfeeding, or weight gain, as instructed by physician)
2. Diet and/or weight history. Limit to several sentences, summarized, most relevant to the problem
(calories consumed, about food or exercise habits, pattern of meals/snacks (or lack of it), nutritional
adequacy of overall intake)
Action 3. Nutrient inadequacies from nutrition assessment
4. Need to provide different food…; to instruct or not
5. Patient attitude to food, new foods, or diet as served or educated on
6. Patient understanding (or lack of) by planning menus, answering or asking questions
7. Expected weight loss or gain, other expected changes
8. Expected diet adherence (+ and – toward compliance)
9. Goal setting- specifics

1. Will….gather more information….say which YOU will gather


2. Recommend…. as, further referrals
3. Recommend diet change to…
4. Recommend vitamin mineral supplement…
Plan
5. Will monitor….food selection, weight every other day, food intake
6. Instruction…general varied food selection…protein source food
7. Recommend pt weigh/measure food
8. Return visit… for follow-up, when and what goal will be reviewed
9. Address selected goal when applicant or participant returns.

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