A SOAP note is a structured method for documenting clinical encounters and is widely used by healthcare professionals to ensure effective communication and continuity of care. The acronym stands for Subjective, Objective, Assessment, and Plan. In cases of poisoning SOAP note example poisoning case, this documentation becomes particularly important as timely and accurate reporting can impact treatment outcomes. Below is a comprehensive SOAP note example based on a poisoning case to demonstrate how this format is applied in real-world clinical practice.
Subjective
The patient is a 28-year-old female who presented to the emergency department complaining of nausea, dizziness, and abdominal pain. She reported ingesting an unknown quantity of over-the-counter acetaminophen tablets approximately six hours prior to her arrival, following an argument at home. She expressed regret and said the ingestion was not a suicide attempt but rather a cry for attention. The patient denied any prior history of mental health disorders or substance abuse. She has no known allergies and is not on any prescription medications. Her last meal was the previous night, and she has not vomited since the ingestion. She complained of feeling warm and drowsy but remained alert during the conversation.
Objective
On physical examination, the patient appeared anxious but was oriented to person, place, and time. Vital signs were recorded as follows: temperature 99.4°F, blood pressure 110/70 mmHg, heart rate 98 bpm, respiratory rate 20 breaths per minute, and oxygen saturation 98% on room air. Her skin was warm with no visible rash or signs of trauma. Pupils were equal and reactive to light. Abdominal examination revealed mild tenderness in the epigastric region without guarding or rebound tenderness. No hepatomegaly or splenomegaly was noted. Neurological examination was normal. A urine pregnancy test was negative. Laboratory work-up revealed elevated liver enzymes with ALT at 312 U/L and AST at 285 U/L. Serum acetaminophen level was found to be significantly elevated at 150 mcg/mL, placing her in the potentially toxic range based on the Rumack-Matthew nomogram.
Assessment
The patient is suffering from acute acetaminophen poisoning. The ingestion occurred approximately six hours ago, which is within the window where intervention with N-acetylcysteine (NAC) is highly effective. Given the elevated acetaminophen levels and liver enzymes, this is considered a moderate poisoning case with potential for hepatic injury. There is no evidence of co-ingestants or suicidal ideation at this time, but a psychological evaluation is warranted. The patient remains hemodynamically stable and exhibits no signs of encephalopathy or coagulopathy, which suggests early-stage toxicity rather than fulminant hepatic failure.
Plan
- Begin N-acetylcysteine protocol intravenously, following the 21-hour regimen.
- Admit the patient for observation and serial monitoring of liver function tests, coagulation profile, and renal function.
- Monitor vital signs every 2 hours and assess for any signs of liver failure, including jaundice, confusion, or bleeding tendencies.
- Consult the poison control center for confirmation of the treatment plan and further recommendations.
- Arrange for a psychiatric evaluation to assess mental health status and risk of future self-harm.
- Provide supportive care including intravenous fluids and antiemetics as needed.
- Educate the patient about the dangers of acetaminophen overdose and the importance of mental health support.
- Plan for discharge only after stable liver function tests and a favorable psychiatric assessment.
This SOAP note example for a poisoning case illustrates the importance of systematic documentation in medical settings. By clearly recording the patient’s subjective complaints, objective findings, clinical assessment, and planned interventions, healthcare providers can ensure appropriate and timely treatment. In poisoning cases, particularly with substances like acetaminophen that can cause delayed but serious complications, early identification and proper treatment are critical. Using the SOAP note format helps streamline care, reduce errors, and improve communication among multidisciplinary teams involved in patient management.
