medical progress notes on nursing home residents

Introduction

Recommended format is the 'SOAP' note.

Subjective:

• new complaints
• symptoms related to active medical conditions

Objective

• general appearance
• weight
• vital signs
• physical findings relevant to
  • new complaints
  • active medical conditions
• reports from nursing staff
  • functional status
  • behavior
• progress in rehabilitation (if relevant)
• reports of other interdisciplinary team members
• laboratory data
• consultant reports

Assessment

• presumptive diagnosis of new complaints or changes in status
• stability of active medical conditions
• response to interventions
  • psychotropic medications
  • rehabilitation
  • other

Plan

• changes in medication or diet
• nursing interventions
  • monitoring of vital signs
  • skin care
  • other
• assessments by other services
  • rehabilitation therapists
  • consultants
• laboratory studies
• discharge planning (if relevant)

Additional terms

• annual physician review of long term nursing home residents