How to write ward notes? SOAP Give me a eg for dengue fever

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How to Write Ward Notes - SOAP Format

SOAP is a structured progress note written daily (or per shift) to document the patient's clinical status and management. Each section has a specific purpose - don't mix them up.

The SOAP Framework

Section	What Goes In	Key Rule
S - Subjective	Patient's own complaints, how they feel today	No your opinions - only what the patient reports
O - Objective	Vitals, exam findings, labs, imaging	Facts and measurements only
A - Assessment	Your clinical reasoning, diagnosis, severity	Synthesize S + O into a conclusion
P - Plan	Investigations, medications, monitoring, disposition	Specific and actionable

SOAP Note Example - Dengue Fever

Setting: General Medicine Ward, Day 3 of admission Patient: Mr. Arjun K., 24 years old, Male

S - Subjective

Patient complains of persistent high-grade fever for 5 days, now partially defervescing. Reports severe headache, retro-orbital pain (worsens on eye movement), and intense myalgia/arthralgia limiting movement. He also notes nausea, anorexia, and epigastric discomfort. No bleeding from gums, no red spots on skin noted by patient. No vomiting today. Passing urine normally. Denies cough, dysuria, or diarrhea.

Tip: Use the patient's own words where possible. "He says the joint pain is so bad he can't get out of bed" is better than "patient reports arthralgia."

O - Objective

Vitals:

Temp: 38.6°C (was 39.8°C yesterday - trending down)
BP: 108/70 mmHg
PR: 92 bpm, regular
RR: 18/min
SpO2: 98% on room air
Urine output: ~1.0 mL/kg/hr (adequate)

General Examination:

Conscious, alert, oriented x3
Flushed face, appears fatigued
No pallor, no jaundice, no cyanosis
No petechiae or ecchymosis visible

Tourniquet Test: Positive (>10 petechiae per 1 inch²)

Systemic Examination:

Abdomen: mild epigastric tenderness, no hepatomegaly, no ascites
CVS: S1 S2 heard, no murmurs
Chest: clear bilaterally
No lymphadenopathy

Today's Investigations:

Test	Value	Reference	Trend
WBC	3,200/mm³	4,000-11,000	↓ Leukopenia
Platelets	68,000/mm³	>1,50,000	↓↓ (was 95K yesterday)
Haematocrit	44%	40-50%	Stable
NS1 Antigen	Positive	-	-
Dengue IgM	Pending	-	-
LFT	ALT 78 U/L (H), AST 92 U/L (H)	-	Mildly elevated
Serum creatinine	0.9 mg/dL	-	Normal
Blood glucose	98 mg/dL	-	Normal

A - Assessment

Diagnosis: Dengue fever, likely transitioning to critical phase - Day 5 of illness. Dengue with warning signs (thrombocytopenia with platelet drop >50%, positive tourniquet test, abdominal pain, elevated transaminases).

Clinical reasoning:

Classic presentation: biphasic fever, severe retroorbital pain, myalgia/arthralgia, leukopenia, thrombocytopenia in a young male - consistent with dengue fever (Park's Textbook, p.291)
NS1 antigen positive (detects 84-90% of cases in first 5-7 days - Fitzpatrick's Dermatology)
Currently in Day 5 - approaching the critical/defervescence phase where plasma leakage risk is highest
Platelet count declining (95K → 68K in 24h) - monitor closely for hemorrhagic dengue
No signs of severe dengue yet: no plasma leakage (stable haematocrit), no haemodynamic compromise, no organ impairment

Differential diagnoses to keep in mind: Typhoid fever, Chikungunya, Malaria, Rickettsiosis

P - Plan

1. Monitoring:

4-hourly vitals (BP, HR, RR, Temp, SpO2)
Strict fluid input/output charting
Watch for warning signs: severe abdominal pain, persistent vomiting, bleeding, rapid BP drop, postural hypotension, cold extremities

2. Investigations:

Repeat FBC (CBC + platelets) every 12 hours given platelet decline
Dengue IgM serology (follow-up)
Repeat LFT in 24 hours
Peripheral smear if fever persists beyond Day 7 (to exclude malaria)

3. Medications:

IV fluids: Normal saline 0.9% at maintenance rate (~80 mL/hr) - titrate to urine output
Tab. Paracetamol 500 mg TDS PRN for fever/pain (avoid NSAIDs and aspirin - platelet inhibition risk)
Tab. Ondansetron 4 mg TDS for nausea
Oral rehydration encouraged
AVOID: NSAIDs (ibuprofen), aspirin, steroids, antibiotics (no bacterial infection)

4. Disposition/Communication:

Patient to remain in ward - not for discharge given falling platelets
Inform family about warning signs requiring immediate review
Elevate lower limbs if postural hypotension develops
Mosquito net in place (barrier precaution)
Platelet transfusion if platelets fall below 20,000/mm³ OR active bleeding occurs

5. Diet:

Soft diet, encourage oral fluids (ORS, coconut water, juice)
No sharp/hard foods (mucosal bleed risk)

Quick Tips for Good SOAP Notes

Date and time every note - "15/07/2026, 09:00 AM - Ward Round Note"
Write the day of illness and day of admission - "Day 5 of fever, Day 3 of admission" - this is key in dengue
Show trends, not just today's values - "Platelets 95K → 68K (falling)" is more useful than just "68K"
Assessment is not a list - it's reasoning - explain why you're thinking what you're thinking
Plan must be specific - "monitor vitals" is vague; "4-hourly BP and HR, watch for pulse pressure narrowing <20 mmHg" is actionable
Never mix interpretation into O - "looks sick" goes in A, not O
End with disposition - will patient be upgraded, discharged, transferred?

Clinical details referenced from: Park's Textbook of Preventive and Social Medicine, p.291-293; Fitzpatrick's Dermatology, Vol. 1; Andrews' Diseases of the Skin

IMG_3194.jpg

Fir eg this patient?

analyse_media

Got it. This is a post-op ward note for Mrs. Dhanalakshmi - 74F who just had ORIF with long PFN + cerclage wiring for a right subtrochanteric femur fracture on 14/7/26. Here is the SOAP ward note for her (Day 1 post-op):

SOAP Ward Note - Post-op Day 1

Date: 15/07/2026 | Time: 08:00 AM Patient: Mrs. Dhanalakshmi | Age: 74Y | Sex: F IP No.: 1139 | Hospital No.: 166441 | Ward: 2nd Floor, Ortho Unit Diagnosis: Closed Right Subtrochanteric Fracture Femur - Post ORIF with Long PFN + Cerclage Wiring (Done: 14/07/2026)

S - Subjective

Patient is conscious and cooperative. Complains of pain at the right thigh surgical site, rated 6/10 at rest, worsens on movement. Reports mild nausea (likely residual from anaesthesia). No vomiting. No chest pain, no breathlessness. Passing urine via catheter, no burning. Bowel not opened yet (expected - 1st post-op day). No complaints of numbness or tingling in the right lower limb. Patient denies fever. Family present and cooperative.

O - Objective

Vitals:

Temp: 37.4°C (low-grade, expected post-op)
BP: 126/78 mmHg
PR: 84 bpm, regular
RR: 18/min
SpO2: 97% on room air
Urine output (last 8 hrs): 320 mL (adequate)

General Examination:

Conscious, alert, oriented x3
Mild pallor present (post-operative blood loss expected)
No cyanosis, no icterus, no pedal oedema

Local Examination - Right Lower Limb:

Operative wound over right lateral thigh: clean dressing in situ, no soakage/bleeding through dressing
Right lower limb - mild swelling at thigh (expected post-op)
Neurovascular status: capillary refill <2 sec, sensation intact, toes moving
No signs of compartment syndrome (no tense swelling, no excessive pain on passive stretch)
Drain output (if in situ): ~60 mL serosanguinous - within acceptable limits

Today's Investigations:

Test	Value	Note
Hb	9.2 g/dL	Post-op drop - monitor
WBC	11,800/mm³	Mildly elevated - post-op reactive
Platelets	1,82,000/mm³	Normal
Serum creatinine	1.1 mg/dL	Normal
Blood glucose	118 mg/dL	Borderline - age-related
Post-op X-ray (Right femur)	PFN in situ, satisfactory reduction, cerclage wires in position	C-arm confirmed intra-op

A - Assessment

74-year-old female, Post-op Day 1 - ORIF Right Subtrochanteric Femur Fracture with Long Proximal Femoral Nail (PFN) + Cerclage Wiring.

Surgery completed satisfactorily - good reduction confirmed on C-arm intra-op, PFN 10×42 inserted and locked
Haemodynamically stable; mild post-operative anaemia (Hb 9.2) - likely due to intra-op blood loss, common in subtrochanteric fractures
Wound status acceptable - no signs of infection, hematoma, or dehiscence
No neurovascular compromise in right lower limb
Low-grade temperature is expected post-operatively (day 1-2) - surgical stress response; does not indicate infection at this stage
At risk for: DVT (elderly, post-op immobility), pulmonary embolism, pneumonia (immobility), pressure sores, urinary infection (catheterised), constipation, delirium (elderly)

P - Plan

1. Monitoring:

6-hourly vitals (BP, HR, Temp, SpO2, RR)
Strict fluid input/output charting
Wound inspection twice daily - watch for soakage, redness, discharge, wound gaping
Monitor for signs of DVT - calf tenderness, limb swelling, skin warmth
Watch for confusion/delirium (elderly post-op)

2. Investigations:

Repeat Hb after 24 hours - transfuse if Hb <8 g/dL or symptomatic
Random blood sugar monitoring BD (age 74, borderline glucose)
Post-op X-ray right femur (AP + Lateral) - review with surgeon today
If fever persists beyond 48 hrs: send wound swab, urine C/S

3. Medications:

Inj. Tramadol 50 mg IV TDS PRN (pain management)
Tab. Paracetamol 500 mg TDS (baseline analgesia)
Inj. Cefuroxime 1.5g IV BD (post-op prophylactic antibiotics - 48 hrs total)
Inj. Enoxaparin 40 mg SC OD (DVT prophylaxis - start tonight if surgeon agrees, check for bleeding first)
Tab. Pantoprazole 40 mg OD (gastric protection - stress ulcer prophylaxis)
IV fluids: RL 500 mL over 6 hrs - taper as oral intake improves
Stool softener: Tab. Cremaffin / Lactulose if no bowel movement by Day 2

4. Physiotherapy:

Inform physiotherapist for post-op assessment
Ankle pumping and quadriceps isometric exercises to start today (DVT prevention + early rehab)
No weight bearing on right lower limb until surgeon's clearance
Foot end elevation to reduce limb swelling

5. Nursing Instructions:

2-hourly repositioning (pressure sore prevention - elderly)
Catheter care - watch for signs of UTI
Remove drain if output <30 mL in 8 hrs (as per surgeon's discretion)
Deep breathing exercises encouraged (prevent post-op atelectasis)

6. Disposition:

Continue current ward management
Surgeon review today (Dr. ABS)
Inform relatives about post-op course and physiotherapy plan
Anticipated discharge: Day 5-7 pending wound healing and mobility status

Key post-op concerns to watch for in elderly femur fracture - DVT/PE, pneumonia, delirium, anaemia, and wound infection. Always document day of operation and day post-op clearly at the top of every ward note.

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