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Opd Soap Format: For Follow Up Patients

This document outlines the OPD SOAP format for follow up patients. It includes sections for vital signs, physical exam findings organized by body system, assessment, plan, and signature. The physical exam includes assessment of general appearance, HEENT, heart, lungs, abdomen, extremities, and neuro. The plan addresses diet, diagnostics, medications, and instructions for care at home including hygiene and immunizations.

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Mica
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348 views2 pages

Opd Soap Format: For Follow Up Patients

This document outlines the OPD SOAP format for follow up patients. It includes sections for vital signs, physical exam findings organized by body system, assessment, plan, and signature. The physical exam includes assessment of general appearance, HEENT, heart, lungs, abdomen, extremities, and neuro. The plan addresses diet, diagnostics, medications, and instructions for care at home including hygiene and immunizations.

Uploaded by

Mica
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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OPD SOAP FORMAT: FOR FOLLOW UP PATIENTS

Patient’s Name (Last/First/Middle) Registration No.


Department Age Gender

Vital Signs:

Head circ:____________cm(obtained if less than year old) Chest circ: ____________cm(obtained if less than year old)
Blood Pressure: _______________mmHg Pulse / Cardiac rate:__________bpm
Respiratory rate: _______________cpm Temp:_______________’C
Length/Height: _________________m/ft Weight:______________kg

Informant:
Reliability:
Contact number:

Date and Time:

CC> follow-up
S
 Patient was last seen and examined on__________ with a diagnosis
of_________and was given the following home medications_________
IBW
With the following (maternal/paternal) subjective complaints:__________
(Ideal body
weight):
 Patient is awake, alert (descriptors for neonate) / conscious, coherent (descriptors for 1 year and older
sabi ni doc, coherent kapag nakakapagsalita na),
not in cardiorespiratory distress, hydrated (ask doc if hydrated or not, minsan kami
BMI na rin nag-aassess, minsan sila doc nagsasabi)
(Body Mass
Index):  HEENT
- Pink/pale palpebral conjunctivae, white/icteric sclerae, patent ear canal and
Nostrils (for children less than one year old) or intact tympanic membrane (for
children >1 year old), pink/pale, boggy turbinates, moist/dry lips, moist buccal
TCR (Total Caloric mucosa. With/without palatal petechiae, pink/hyperemic pharyngeal walls,
Requirement): hypertrophic tonsils
- Supple neck, no/ with tender/non tender, movable/fixed, palpable cervical
lymph nodes (location, size, shape, consistency, temperature, tenderness, margin,
TFR (Total Fluid laterality, discreteness)

Requirement):
 HEART
- Adynamic precordium, normal rate/tachycardic and regular/irregular rhythm, no
murmur/murmur & grade
Growth chart
interpretation:  CHEST/LUNGS
ie. “No stunting, no - Symmetrical chest expansion, no/shallow/deep, intercostal, subcostal,
wasting’’ supraclavicular/universal retractions, clear/muffled/trasnmitted breath sounds,
with good/fair/tight air entry (mention if with stridor, crackles, wheezes, rales), vocal fremitus
Family History:
ie. With  ABDOMEN: Inspection, Auscultation, Palpation, Percussion
Paternal/maternal - Soft/rigid/with muscle guarding, flat/slightly globular/globular/ flabby abdomen,
history of asthma, normoactive/hypoactive/hyperactive bowel sounds, tenderness (note location), no
allergies, PPTB, masses
pneumonia - If NEWBORN Describe umbilical stump
 Dry/moist/with discharge/foul smelling discharge/erythema surrounding the
area/ still with umbilical clamp
 EXTREMITIES
- No gross deformities, full and equal pulses, Capillary refill time < 2 secs
- No active dermatoses (neonates: if with diaper rashes, erythematous, location)

 GENITALIA
- Normal looking male/female external genitalia
- With/without rashes

 NEURO
- Never indicate essentially normal if neuro PE is not done
A
 Diagnosis ni doc, tho sabi ni doc Aquino, mas gusto niya if may diagnosis na tayo
T_T
 Example: Primary Pulmonary Tuberculosis- 5th month ongoing treatment
 Acute nasopharyngitis probably viral

P
 Diet
- Diet as tolerated/Diet for age
- Increase oral fluid intake (if more than 6 months na)
- Continue breastfeeding/formula milk feeding
- May start complementary feeding (pureed/finger food/lumpy/table food)
- Hypoallergenic diet
- Avoid_________

 Diagnostics

- For urinalysis
- For Fecalysis
- For Complete blood count with platelet count
- For X-ray

 Drugs
- Started ________ (include dose and TD)

 Disposition
- Advise proper hygiene and daily bathing
- Advise proper and frequent hand washing
- Advise frequent diaper change to avoid diaper rash
- Advise chest physiotherapy every after nebulization

- For neonates and infants:


 Burp baby after every feeding
 Expose to sunlight for 15 minutes daily between 6 am to 8 am

- Clean cord daily with 70% isopropyl alcohol


- If with ear problem:
 Advise proper aural toilette
 Advise to avoid ear manipulation

- Update immunizations (note the vaccines/boosters needed according to age)


- Concerns addressed
- Instructions given
- Advised to come back with result or if with problem

DR. AQUINO/CHUA/JI (trodat)

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