In the realm of clinical documentation, the SOAP note stands as a vital structure for recording patient encounters. The acronym stands for Subjective, Objective, Assessment, and Plan. In the case of poisoning, a clear and concise SOAP note becomes even more crucial SOAP note example poisoning case, as it ensures timely medical response and accurate case tracking. Poisoning cases can vary significantly in presentation depending on the substance involved, dosage, duration since exposure, and the patient’s physiological condition. The following example illustrates a well-documented SOAP note for a poisoning case, incorporating realistic elements aligned with clinical practice.
Subjective
The patient is a 28-year-old female who presented to the emergency department with complaints of nausea, vomiting, abdominal cramps, and dizziness. The symptoms began approximately two hours before arrival. According to the patient, she accidentally ingested an unknown quantity of acetaminophen tablets while under emotional distress. She reports feeling increasingly drowsy and unable to concentrate. She denies any prior history of mental illness but admits to taking medication for headaches regularly. No history of allergies was reported. She lives alone and the incident was discovered after a friend visited unexpectedly. No alcohol or recreational drug use was disclosed.
Objective
Vital signs on arrival were recorded as follows: temperature 37.4°C, pulse 102 bpm, respiratory rate 20 breaths per minute, blood pressure 110/70 mmHg, and oxygen saturation 97% on room air. The patient appeared anxious, mildly diaphoretic, and was oriented to person and place but not time. Physical examination revealed mild right upper quadrant abdominal tenderness with no guarding or rebound tenderness. Neurological exam was non-focal. Pupils were equal and reactive to light. Cardiovascular and respiratory examinations were unremarkable. No rashes or external injuries were observed. A bottle of acetaminophen (500 mg per tablet) was found in her purse, with over 30 tablets missing based on label count. Initial labs including CBC, liver function tests, and acetaminophen serum levels were ordered. Point-of-care glucose was within normal range.
Assessment
The clinical picture suggests acute acetaminophen overdose, likely in the 15-20 gram range based on standard dosing and pill count. Given the timing of ingestion (within 2-3 hours) and current clinical signs, the patient is at risk of developing hepatotoxicity. Early signs of poisoning, such as nausea, vomiting, and abdominal pain, are present, which are consistent with the first stage of acetaminophen toxicity. The serum acetaminophen level and liver enzyme levels will provide additional clarity on the extent of toxicity and inform antidotal treatment strategy. The patient’s mental state suggests possible underlying psychological distress that may have contributed to the event. A psychiatric consultation is warranted to assess for intentional overdose and suicide risk.
Plan
- Initiate N-acetylcysteine (NAC) therapy immediately as a precaution, pending lab confirmation, due to time sensitivity and potential for liver injury. 2. Administer activated charcoal as the patient presented within the window where gastrointestinal decontamination may still be effective and beneficial. 3. Place the patient under close observation in the emergency department with continuous monitoring of vital signs and mental status. 4. Repeat liver function tests and acetaminophen levels at appropriate intervals to monitor progression. 5. Schedule urgent psychiatry evaluation to assess for suicidal ideation or intent. 6. Engage social worker to coordinate family support and possible admission to a mental health facility post-medical stabilization. 7. Educate the patient about medication safety, overdose risks, and refer for follow-up with primary care and behavioral health services after discharge. 8. Document all steps thoroughly for legal and clinical continuity.
Conclusion
This SOAP note example outlines a structured approach to a poisoning case, providing a clear representation of the patient’s presentation, examination findings, clinical judgment, and treatment plan. In cases involving toxic ingestion, early identification and standardized documentation using the SOAP framework can significantly influence the clinical outcome. It also enables interdepartmental collaboration, especially between emergency medicine, toxicology, and psychiatry teams. Maintaining thorough documentation ensures that critical interventions are tracked, which is essential for patient safety, legal protection, and continuous care. Understanding how to write an effective SOAP note for poisoning cases is a vital skill for healthcare providers managing emergency toxicological events.