SOAP Documentation

Subjective, Objective, Assessment, Plan (SOAP) Documentation⁽¹⁾
(Note — may include subheadings)

Date:
Dietitian sticker:
Time:
Thank you for referring this            year old man/woman/child with

SUBJECTIVE *Data from patient/caregiver, e.g. Food/Nutrition-Related History. Include diet recall/food allergies.*
S	Patient states: Patient c/o e.g. nausea, vomiting, decreased appetite Previous dietetic input or other nutrition support Diet history information collected from patient (may refer to an attached form) and reported physical activity. Patient’s questions, reported knowledge, stated beliefs and attitudes, reported prior dietitian contact or nutrition education, reported previous dieting history and social history. e.g. Patient reports signs and symptoms such as nausea/vomiting/decreased appetite
OBJECTIVE Physical evidence, e.g. Anthropometric Measures, Biochemical Data, Medical Tests and Procedures.
O	Data gathered from other parts of medical record Medical diagnosis including day post-injury "Medical condition noted" Co-morbidities, e.g. type 1 diabetes/CVD Treatment plan Medications noted (if relevant to nutritional support) Current diet/nutritional support, e.g. clear fluid/texture modified Biochemistry/tests/procedures Measurements taken in nutrition clinic or inpatient Height, weight, BMI, desirable weight range, goal weight, weight used in calculations, usual weight, weight history (% loss or gain), skinfolds Indirect calorimetry measurements Nutrition-focused physical examination findings GI information/bowel motions/other Temperature/infection Relevant social history Nutrition-focused physical examination findings SGA, PG-SGA, Mini Nutrition Assessment Long Form Household security tools Food variety tool ratings
ASSESSMENT *PES Statement: Problem, Etiology, Signs and Symptoms (overall nutrition status).*
A	Assessment and interpretation of subjective and objective data Current requirements: energy, protein, etc. and calculations used, e.g. kcal/kg Measured RMR, Mifflin-St Jeor or other equations, use of PAL for physical activity factor or injury factor Estimates of nutrient content and adequacy or comparison to appropriate comparative standard (past nutrition prescription, national dietary guidelines) Drug therapy interactions, side effects, nutrient-drug interactions Assessment of knowledge, motivation, stage of change If re-assessment Determination if monitoring and evaluation indicators have been achieved Status of Nutrition Diagnosis from previous nutrition consultation/nutrition progress note Judgment of success of previous nutrition intervention; rationale if changes are needed Current PES statements reflecting most urgent problems to be addressed at this time
PLAN Nutrition Prescription and Nutrition Intervention Details. Monitoring and Evaluation Plan.
P	Nutrition Prescription/Nutrition Intervention description Describe changes in diet order needed (if inpatient) Describe Nutrition Education topics, assessment of patient’s knowledge and educational materials provided Describe Nutrition Counseling provided and behavioral changes agreed upon Describe coordination of care if needed (laboratory tests needed, medication adjustments, other referrals) Nutrition Monitoring and Evaluation Plan Specific indicators and criteria for success, time frame and frequency of monitoring Plans/topics for inclusion at follow-up consultation (also less urgent nutrition diagnoses to be addressed)

1. Academy of Nutrition and Dietetics. Nutrition Care Manual. Accessed 17 August 2020. Available from: https://www.nutritioncaremanual.org

Updated August 16, 2020

SOAP Documentation

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