The physical exam SOAP note is a crucial documentation tool used by healthcare professionals to record a patient’s physical examination findings in a structured and organized manner. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. While the subjective and assessment portions of the SOAP note focus on the patient’s reported symptoms and the healthcare provider’s diagnosis respectively, the objective section is where the physical exam findings are documented. Here, we’ll explore 8 examples of physical exam findings that might be included in the objective section of a SOAP note, demonstrating how these findings are crucial for easy and effective documentation:
1. Vital Signs
- Blood Pressure: 120⁄80 mmHg
- Heart Rate: 72 beats per minute
- Respiratory Rate: 16 breaths per minute
- Temperature: 98.6°F (37°C)
- Oxygen Saturation: 98% on room air
2. General Appearance
- The patient appears well-developed and well-nourished, lying comfortably in bed, with no signs of distress.
3. Head and Neck Examination
- Head: Normocephalic, no signs of trauma.
- Eyes: Pupils are equal, round, and reactive to light and accommodation (PERRLA).
- Ears: Canals are clear, tympanic membranes are intact.
- Nose: No discharge or deformity.
- Throat: Mucous membranes are moist, no exudate.
4. Respiratory Examination
- Lungs: Clear to auscultation bilaterally, no wheezes, rhonchi, or rales.
- Breath Sounds: Normal, with equal expansion of the chest.
5. Cardiovascular Examination
- Heart: Regular rate and rhythm, no murmurs, gallops, or rubs.
- Peripheral Pulses: 2+ in all extremities, capillary refill less than 2 seconds.
6. Abdominal Examination
- Abdomen: Soft, non-tender, non-distended, with active bowel sounds.
- Liver and Spleen: Not palpable.
7. Musculoskeletal Examination
- Muscle Strength: 5⁄5 in all major muscle groups of the upper and lower extremities.
- Range of Motion: Full and unrestricted.
8. Neurological Examination
- Mental Status: Alert and oriented to person, place, and time.
- Cranial Nerves: II-XII grossly intact.
- Reflexes: 2+ and symmetric in the upper and lower extremities.
- Sensation: Intact to light touch, pinprick, vibration, and proprioception.
Example of a Complete Objective Section:
“The patient is a well-developed, well-nourished individual who appears comfortable. Vital signs include blood pressure 120⁄80 mmHg, heart rate 72 beats per minute, respiratory rate 16 breaths per minute, temperature 98.6°F (37°C), and oxygen saturation 98% on room air. The general physical examination reveals a normocephalic head, PERRLA eyes, clear ears, a normal nose and throat, and clear lungs to auscultation. The cardiovascular examination shows a regular heart rate and rhythm without murmurs. The abdominal examination is significant for a soft, non-tender, and non-distended abdomen with active bowel sounds. The musculoskeletal examination demonstrates 5⁄5 muscle strength in all major groups and a full range of motion. Neurologically, the patient is alert and oriented with grossly intact cranial nerves and symmetric reflexes.”
These examples illustrate the breadth and depth of information that can be included in the objective section of a SOAP note following a physical examination. By systematically documenting findings, healthcare providers can ensure comprehensive and accurate patient assessments, facilitating effective care and communication among the healthcare team.
