SOAP Notes are used in MOWINS for high-risk participants. In writing SOAP notes, use standard abbreviations.  A list of standard abbreviations is available in the Health and Nutrition Assessment Handbook (HNAH), located in the WOM.” 

Start Note by: MOWINS will capture this
Date & Time: MOWINS will capture this

 

Subjective

1. Patient, significant other, family, or staff tells the professional
2. Can include symptoms, feelings, history, and progress
3. May be in format of ‘patient reports…’ or given as a direct quote, as, “I don’t have any appetite at all today.”
4. These statements are chosen to illustrate a point made in the assessment
5. No more than 1 or 2 well-chosen statements necessary

Objective
1. SPECIAL DIET:
2. ANTHROPOMETRIC DATA: (Height, weight, IBW, % IBW, % usual weight, TSF percentile and/or % std, AMC percentile and/or % std)
3. LAB RESULTS: (1/21 Albumin 3.5, Total Lymphocyte County 1367, etc)
4. CLINICAL OBSERVATIONS RELATING TO NUTRITIONAL ASSESSMENT: (+ or – edema, emaciation, decubitous ulcer)
5. DIET: [Nutrition Assessment revealed]
6. MEDICATIONS: (Note the ones SPECIFICALLY relevant to nutritional status)
7. REPORT OF EDUCATION: (Instructed pt on ____ diet; Materials given ….)

Assessment
Interpretation of
1.Caloric needs for …(weight loss, breastfeeding, or weight gain, as instructed by physician)
2.Diet and/or weight history. Limit to several sentences, summarized, most relevant to the problem
(calories consumed, about food or exercise habits, pattern of meals/snacks (or lack of it), nutritional
adequacy of overall intake)
3.Nutrient inadequacies from nutrition assessment
4.Need to provide different food…; to instruct or not
5.Patient attitude to food, new foods, or diet as served or educated on
6.Patient understanding (or lack of) by planning menus, answering or asking questions
7.Expected weight loss or gain, other expected changes
8.Expected diet adherence (+ and – toward compliance)

Plan
1.Will….gather more information….say which YOU will gather
2.Recommend…. as, further referrals
3.Recommend diet change to…
4.Recommend vitamin mineral supplement…
5.Will monitor….food selection, weight every other day, food intake
6.Instruction…general varied food selection…protein source food
7.Recommend pt weigh/measure food
8.Return visit… for follow-up, when and what goal will be reviewed
9.Address selected goal when applicant or participant returns.

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