How to Write a Case Note using the SOAP Method (PowerPoint)

Presented by UIC-CON
State the importance of documenting risk.
Describe how identification of risk impacts
the delivery of quality care and improves
Identify the differences between the old and
new risk inventory.
Explain the expanded content areas covered
in the risk inventory.
Construct a risk inventory on a participant.
To maintain participant’s safety and quality of life.
To create awareness of participants’ risks among
the care team.
To develop a mitigation plan addressing
preventable incidents.
To identify additional supports and/or services
To prioritize risk based on severity of harm.
To evaluate a mitigation plan based on changing
o Complete baseline (MFP requirement)
o Revise as needed, based on change(s) to the
participant’s condition
o Review at least monthly
o Revise as needed, based on change(s) to the
participant’s condition
Complete assessment.
 If your agency does not have a formal assessment, a
demonstration on how to convert the risk inventory into an
assessment will be presented.
Complete MFP Risk Inventory based on
findings from your assessment.
May need to expand assessment based on new areas on the
risk inventory.
80 questions, 10 domains
Physical Health
Behavioral and Emotional Health
Substance Abuse
Self-Harm or Harm to Others
Medication, Laboratory, and Utilization
Functional: ADLs & IADLs
Interpersonal and Social Supports
Engagement, Self-Management, Recovery
Representation of major body systems:
circulatory, respiratory, digestive, intestinal,
urinary, etc.
Includes additional questions on pain,
wounds, sleep, falls, burns, etc.
Assess participant’s knowledge of disease
Assess for presence of acute physical
symptoms (a good indicator of disease
Assess for presence of acute behavioral or
emotional health symptoms (a good indicator
of disease management).
Symptoms identified include disorganized
thought processes, false sensory perceptions,
social withdrawal, mood changes, anxiety,
This domain focuses on presence of
symptoms rather than self-management of
Assess for current signs of substance abuse
and risk for relapse.
Assess for history of substance abuse.
Assess for history or current engagement in
criminal activity (i.e., arson, gang activity,
property destruction).
Assess for history or current engagement in
risky behaviors (i.e., unhealthy sexual
Assess for history of suicidal and/or homicidal
Assess for history or current vulnerability for
abuse, neglect, or exploitation.
Assesses for presence or risk of diminished
cognitive functioning resulting in impaired
judgment, impaired problem solving ability,
or lack of orientation.
Assess participant’s knowledge, ability, and
adherence to medication management.
Assess for lack of primary care services.
Assess for frequent utilization of emergency
Assess participant’s ability to perform
Activities of Daily Living (ADLs) and
Instrumental Activities of Daily Living
Assess need and proper use of assistive and
adaptive devices.
Assess participant’s home and neighborhood
for accessibility and safety (e.g., accessibility
of home, availability of community
Assess engagement and quality of
interpersonal relationships (e.g., presence of
social support system, healthy interactions).
Assess engagement in plan of care (e.g.,
motivation, trust, interest, understanding,
historical success).
Identify barriers that negatively affect plan of
Each question is equivalent to a risk.
Check ‘Yes’ if risk was identified
Check ‘No’ if risk was not identified
For each risk identified, you will be asked to “Describe why
this is a risk for the participant” – This is where you enter
data from your assessment.
Then, you will be asked (for each risk identified) to “Describe
how this risk will be mitigated before and after transition” –
This is your mitigation plan.
In the mitigation plan, you are asked to develop
individualized strategies to mitigate a known risk using an
action verb (i.e., evaluate, educate, coach, arrange,
coordinate, etc.).
Risk Inventory is a tool used to organize
assessment findings into specific content
Conducting a comprehensive assessment is
significant to risk identification.
Developing tailored strategies specific to the
participant is consequential to risk mitigation.
Presented by UIC-CON
At the end of this session, the learner will be able to:
 Define the importance of documenting case notes.
 Describe the SOAP method for documenting case
 Illustrate when, where, and how to document a case
 Construct a case note in the MFP CRM Web
Keeps provider(s) abreast on current
treatment plan and ongoing developments
Provides the care team with a mechanism to
communicate with one another
Supports an action by demonstrating
providers’ engagement with participant
Provides a representation of the participant
and his/her progress before and after
 After a home visit with an MFP participant
and/or caregiver
 After a phone call with an MFP participant
and/or caregiver
 After an office visit with an MFP participant
 Documentation of case notes is ongoing, pre-
and post-transition.
 Use the notes feature to document contacts.
 Click the “+” sign to add a new note (upper right
hand corner).
Select Contact Date
Select Contact Type:
 Face-to-face visit
 Phone call
 Email
 Fax
 Other
 Select Location:
 Participant’s home
 TC’s office
 Hospital/Institutional care setting
 Service Provider’s Office (i.e., psychiatrist)
 Community Provider (i.e., day program)
 Other
Select Persons Contacted (Select All):
 Participant
 Family/Guardian/Significant Other/Power-of-Attorney for Health Care
 Physician
 Hospital Staff (e.g., nurse, social worker, discharge planner)
 Facility Staff
 Community Provider/Worker/Case Manager
 Other Community Based Persons (e.g., friend, lawyer)
 Other
Enter a SOAP Note for contact:
 Subjective findings
 Objective findings
 Assessment findings
 Plan
 Other Notes
 An organized method of documentation used by
providers to describe events involving the
 The SOAP note format is used to facilitate
effective communication among the care team by
providing assessment findings, identifying
problem(s), and developing action plan(s).
Describe how the participant feels.
 Example: Jack reports he is “feeling well and has no concerns.”
Document what the participant says about his/her current living situation.
 Example: Susan reports she is “happy, healthy and enjoying her new
Record participant’s exact words to describe his/her health.
 Example: John reports he has a “dull headache” and it has lasted over a
Document any mention of changes to his/her medications, diet, activity
level, etc.
 Example: When Sarah went to visit her family doctor this week, he told
her she had “high blood pressure and added a new medication.”
Document objective data including blood
pressure and/or blood glucose readings, and
findings from physical assessment (i.e.,
noticeable scraps or cuts, tearfulness, etc.).
 Example: TC checked Henry’s blood pressure log
and found his last three readings were all within
normal limits, 122/78, 120/76, and 122/80.
Document your interpretation of the
subjective and objective findings.
 Example: Courtney met with a dietician last
week to discuss how to follow a diabetic diet.
Courtney stated an understanding and
compliance with following a diabetic diet.
However, her personal assistant reported that
Courtney was eating a ½ gallon of ice cream
weekly and drinking a 2L of pop daily.
Document plan on addressing assessment finding (address each
abnormal finding).
 Example: Create food diary with Courtney and follow-up weekly.
Take Courtney grocery shopping weekly and teach her how to read
food labels and choose healthy foods.
Report any issues or barriers to implementing this action plan.
 Example: The nearest grocery store with a variety of fresh fruits and
vegetables is 45 minutes away.
Document follow-up to action items.
 Example: TC re-visited Courtney a month later and found her blood
glucose readings were consistently over 200 mg/dl. TC will arrange
for Courtney to meet with her dietician and primary care provider to
discuss strategies to improve diabetic management.
Ruth is a 47-year old female who has resided at We Care nursing facility for
the past two years. Her admitting diagnosis was major depressive disorder,
alcohol abuse and paraplegia.
At the time of her admission, Ruth was involved in a motor vehicle accident
while driving under the influence of alcohol. She was not taking any
medications and consumed a 24-pack of beer weekly for 15 years.
Ruth’s medical history includes hypertension, chronic liver disease, chronic
renal disease, secondary hyperparathyroidism, hepatic encephalopathy, and
paraplegia. She is taking eight different medications for her physical and
mental health. She uses a motorized wheelchair for mobility.
Ruth has stabilized at We Care and is excited about moving into her own
Physical Health Domain
Substance Abuse Domain
Interpersonal and Social Supports Domain
Functional Domain
Contact On: 8/24/14
Contact Type: Face-to-face contact
Location: Participant Home
Persons Contacted: Participant
 SOAP Note
 Subjective findings: Ruth stated, “I hate living here and want to move.”
 Objective findings: Ruth was tearful and in distress.
 Assessment findings: This is her first week living in her new apartment. Ruth
has a history of depression and is prescribed Zoloft 50 mg in the evening. Her
support system is sparse. She is connected with a community psychiatrist and
 Plan: Discuss what she likes and dislikes about her apartment. Develop
strategies on how improve her current living situation. Inquire about
medication compliance and substance abuse. Administer depression
screening tool and compare findings to baseline results. Provide Ruth with a
crisis hotline number. Offer to sit with Ruth while she calls her counselor, if
needed. Offer to take Ruth on a community outing, if she desires. Follow-up
with Ruth the next day via phone.
Please contact your UIC Pod Leader with any
UIC College of Nursing
Carla Tozer
Brian O’Sullivan
[email protected]
[email protected]
Valerie Gruss
Ryan Reid
[email protected]
[email protected]
Dennis Crowley
Mike Berkes
Justin Wesley
[email protected]
[email protected]
[email protected]
Carrie Berger
Justin Wesley
Jason Immertreu
[email protected]
[email protected]
[email protected]

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