SOAP Note Example for a Telehealth UTI Visit

What should be included in the Subjective section?

In the Subjective section, you'll document what the patient tells you. This includes symptoms, duration, and any relevant medical history. For a UTI visit, focus on:

• Chief Complaint: Burning sensation during urination.
• History of Present Illness: The patient reports burning during urination for the past two days. There's increased frequency but no fever or back pain.
• Past Medical History: No history of UTIs. No known allergies.
• Medications: Currently taking oral contraceptives.
• Social History: Non-smoker, drinks socially.

What goes in the Objective section for telehealth?

In a telehealth setting, the Objective section is limited since you can't perform a physical exam. Focus on observations and any data you can gather:

• General Appearance: The patient appears well and is in no acute distress via video.
• Vital Signs: The patient reports a normal temperature at home, no recent measurements of blood pressure or heart rate.

How do you write the Assessment for a UTI?

The Assessment section is where you diagnose the issue based on the information gathered:

• Diagnosis: Uncomplicated urinary tract infection.
• Differential: Consider other causes of dysuria, but symptoms align with UTI.

What should the Plan include?

The Plan outlines the treatment and follow-up steps. Here's what you might include for a UTI:

• Medication: Prescribe a course of antibiotics, such as nitrofurantoin or trimethoprim-sulfamethoxazole, depending on patient's allergies and local resistance patterns.
• Patient Education: Advise on hydration and signs of worsening symptoms that should prompt a follow-up.
• Follow-Up: Recommend a follow-up call in 3-5 days to reassess symptoms.

How can you ensure thorough documentation?

Thorough documentation is key, especially for telehealth. Ensure you:

• Record patient consent for telehealth.
• Note any technical issues during the call.
• Summarize patient understanding and agreement with the plan.