The SOAP note (Subjective, Objective, Assessment, and Plan) format is a widely accepted documentation method used by healthcare professionals to record patient encounters in a structured and organized manner. In the case of poisoning, accurate documentation using the SOAP note is essential for timely intervention, clinical clarity SOAP note example poisoning case, and ongoing patient monitoring. Below is a comprehensive SOAP note example for a poisoning case, designed to illustrate how this format supports effective clinical management and medical communication.
Subjective (S):
The patient is a 32-year-old male who presents to the emergency department with complaints of nausea, vomiting, abdominal pain, and dizziness. According to the patient, he ingested an unknown quantity of an over-the-counter painkiller—believed to be acetaminophen—approximately four hours prior to arrival in a suicide attempt following a personal crisis. He states he consumed the pills with alcohol. The patient denies any previous suicide attempts but reports feeling “overwhelmed” and “unable to cope.” He also complains of a burning sensation in the upper abdomen and a persistent headache. Family history is unremarkable, and the patient has no known allergies. The patient appears visibly distressed but is coherent and able to answer questions.
Objective (O):
Vital signs upon arrival: Temperature 98.6°F, Blood Pressure 128/84 mmHg, Heart Rate 110 bpm, Respiratory Rate 22 breaths/min, Oxygen Saturation 97% on room air. The patient appears anxious and slightly diaphoretic. Physical examination reveals mild right upper quadrant tenderness on palpation without guarding or rebound tenderness. Neurological exam is non-focal. Pupils are equal and reactive to light. Cardiac and respiratory exams are within normal limits. Laboratory results show elevated liver enzymes (AST: 340 U/L, ALT: 410 U/L), prolonged PT, and low serum bicarbonate. Serum acetaminophen level is significantly elevated at 150 mcg/mL, taken approximately four hours post-ingestion. Blood alcohol level is 0.10%. ECG is normal.
Assessment (A):
Acute acetaminophen toxicity with co-ingestion of alcohol. Based on the timing of ingestion and elevated serum acetaminophen levels, the patient is at high risk of hepatic injury. The presence of elevated liver enzymes further supports hepatocellular damage. Given the suicide attempt, there is also a concurrent psychiatric concern that needs urgent attention. The absence of altered mental status, hemodynamic instability, or respiratory compromise indicates the poisoning is in the early stage, and timely intervention can prevent irreversible damage. Risk factors such as alcohol co-ingestion may exacerbate hepatotoxicity. The patient’s presentation is consistent with Stage I acetaminophen poisoning characterized by gastrointestinal symptoms and elevated liver markers.
Plan (P):
- Initiate N-acetylcysteine (NAC) therapy immediately as per protocol for acetaminophen toxicity. Begin with a loading dose followed by a maintenance infusion over 20 hours. 2. Admit the patient to the medical observation unit for continuous monitoring of vital signs, liver function tests, and coagulation profile every 6 hours. 3. Perform a psychiatric evaluation as soon as the patient is medically stable. Initiate suicide risk assessment and involve the mental health crisis team. 4. Provide IV fluids for hydration and electrolyte balance. Monitor for signs of hepatic encephalopathy and metabolic acidosis. 5. Educate the patient about the risks of acetaminophen overdose and offer counseling upon discharge. Plan for outpatient follow-up with both hepatology and behavioral health teams. 6. Notify the poison control center and document the case details for surveillance and public health reporting.
This SOAP note example of a poisoning case highlights the importance of detailed, structured documentation in medical settings. The Subjective section captures the patient’s narrative and emotional state, which is crucial in poisoning cases involving intentional ingestion. The Objective section offers measurable clinical findings and lab data that guide diagnosis. The Assessment helps prioritize medical concerns and interpret clinical data, while the Plan outlines both immediate interventions and long-term follow-up.
In poisoning cases, especially those involving intentional overdose, a multidisciplinary approach is vital. Prompt treatment with antidotes like NAC can significantly reduce morbidity if started early. Psychological support and risk evaluation ensure that the root cause of the behavior is addressed, reducing the risk of recurrence. Using the SOAP note structure ensures clear communication among healthcare providers and fosters continuity of care throughout the patient’s treatment journey. By applying this method in real-world poisoning scenarios, medical teams can provide timely, targeted, and effective care.