How to Chart a Diabetic Foot Exam in a SOAP Note

What should I include in the Subjective section?

In the Subjective section, note any complaints or symptoms the patient mentions. Ask about pain, numbness, or any changes in sensation. It's also useful to inquire about recent injuries or infections.

• "Patient reports tingling and numbness in both feet."
• "Denies any recent foot injuries or open sores."

How do I document the Objective findings?

The Objective section is where you record your observations and measurements. Check for skin changes, ulcers, and signs of infection. Use a monofilament to test sensation and assess pulses.

• "Skin intact, no ulcers noted."
• "Decreased sensation noted with monofilament testing on the plantar surface of the right foot."
• "Dorsalis pedis pulse 2+ bilaterally."

What goes into the Assessment?

In the Assessment, provide a summary of your findings and what they mean. This is where you diagnose the condition based on the subjective and objective information.

• "Findings consistent with peripheral neuropathy in the context of diabetes."

How should I outline the Plan?

The Plan should detail your next steps for management and follow-up. Include any treatments, referrals, or patient education you recommend.

• "Educate patient on daily foot care and proper footwear."
• "Refer to podiatry for further evaluation."
• "Follow-up in 3 months to reassess foot health."

Any tips for making the SOAP note clear and concise?

Keep your notes focused and use medical terms where appropriate. Avoid unnecessary jargon. Clear, concise notes help ensure continuity of care and improve communication with other healthcare providers.

• Use bullet points for clarity.
• Stick to the facts and avoid adding unnecessary details.
• Review your notes to ensure they accurately reflect the patient's condition and your clinical judgment.