SOAP

You can include a problem list that can incluble:

Dx, Possible Dx, Complaints, and known Dx
Example: 1. Trauma secondary due dog bite on left hand (paw)
2. Left hand cellulitis secondary to dog bite
3. Possible left hand fracture
4. Hip dysplasia
5. Obesity

S (Subjective): This will describe what owner tells you and how owner
describes what pet is feeling. Everything that can not be measured or
quantified (Symptoms in other words). Can be in ONE sentence, very short.
Example: Owner refers that pet was noted to be with decreased appetite,
activity and limping on left hand after a fight while walking pet 2 days ago.
In pain. Owner washed paw but did not disinfect.

O (Objective): Everything that is measurable (Signs).

V/S (vital signs): T:

HR:

RR:

BP:

GA (general Appearance): Hypoactive, hiding left hand, febrile,

acutely ill
HEENT (Head, Ears, Eyes, Nose, Throat): Normocephalic/atraumatic,
moist or dry
mucosa, no secretions or brownish secretions + bad
odor from left ear, pupils reactive to light, menace test normal,
shirmer test normal, etc.
Heart: Regular rate and rhythm, no murmurs found, no rubs or
gallops
Lungs: Clear to auscultation, or left basilar crakles, etc.
Abdomen: Bowel sounds +, No palpable masses, or displays curving
of back when palpated, non-distended, scar from previous OH, insect
bite marks.
Extremity: Left hand swelling, erythema, warmth, very tender to
touch, decreased range of motion due to pain, palpable pulses. Other
extremities are unremarkable.
Neuro: Neuro exam, bla, bla, bla

Labs: Can put only abnormal lab values to save up space or any lab
value that can backup your Dx. (WBC = 20,000)
Radiology: Only relevant findings that can backup Dx. (No fractures
to left hand.)

(assessment): This describes how findings tell you what dx is. It

can be combined with plan to save up space (as A/P
assessment/plan).
Example: Dog with left hand cellulitis secondary to trauma
evidenced signs on PE and increased WBC = 20,000. Wound is
open, dog sleeps outside and has continuously licked hand. No
fracture was found on XR.

(Plan): 1. Debride infected tissue in sterile and controlled setting.

2. Antibiotics administered now and what to give for home
3. Pain medication
4. Followup appointment in 1 month or less I dont know

Using the way I like it:

A/P

: Dog with left hand cellulitis secondary to trauma evidenced

signs on PE and increased WBC = 20,000. Wound is open, dirtycontaminated. Dog sleeps outside and has continuously licked hand.
No fracture was found on XR. His will be debrided on infected tissue in
sterile and controlled setting, will be given ABx and pain meds.
Followup in 2 weeks.

!!!!!!!!!!!!!!!!!!!!!!!
!!!!!! Physical exam in O area can include only relevant system. Do
not do an extensive PE on dog that appears well, does not have
relevant past medical history and only came for flea/tick infection or a
little wound on paw, or if owner thinks she sees something !!!!!!!

Everything can be short. At least enough to describe main problem.