The SOAP note is a widely used method in clinical documentation, offering a structured format that enhances communication among healthcare providers. SOAP stands for Subjective, Objective, Assessment, and Plan. It provides a comprehensive way to document patient encounters, especially in time-sensitive and critical cases such as poisoning. In this article, we will present an SEO-optimized SOAP note example for a poisoning case SOAP note example poisoning case, reflecting the real-world workflow in toxicology and emergency settings.
Subjective
The patient is a 28-year-old female who was brought to the emergency department by her roommate. The roommate reports that the patient was found unconscious in her bedroom surrounded by empty medication bottles. The roommate suspects intentional ingestion of prescription drugs in a suicide attempt. No suicide note was found, but the patient had been emotionally distressed due to recent job loss and a breakup. According to the roommate, the patient was last seen normal approximately three hours prior to discovery. Upon initial awakening, the patient complained of dizziness, nausea, and blurred vision. She denied chest pain or abdominal discomfort but appeared confused and mildly disoriented. Past medical history includes depression and anxiety. No known allergies.
Objective
Vital signs on arrival: Temperature 98.4°F, Blood Pressure 90/60 mmHg, Heart Rate 112 bpm, Respiratory Rate 20 bpm, SpO2 95% on room air. The patient was drowsy but responsive to verbal commands. Pupils were equal and reactive to light, but slightly constricted. Skin was warm and moist. Cardiac and respiratory examinations were within normal limits. Abdominal examination revealed no tenderness or guarding. Neurological assessment indicated mild confusion and sluggish reflexes. No signs of trauma were observed. Electrocardiogram showed sinus tachycardia. Initial toxicology screening was positive for benzodiazepines and tricyclic antidepressants. Serum electrolytes showed mild hyponatremia. Liver and kidney function tests were within normal range. Arterial blood gas analysis indicated mild metabolic acidosis.
Assessment
This is a suspected case of acute drug overdose involving benzodiazepines and tricyclic antidepressants. The clinical presentation is consistent with central nervous system depression, hypotension, and mild metabolic disturbances. The history of depression and the presence of multiple empty medication bottles support the hypothesis of intentional overdose. The patient’s condition, although currently stable, requires close monitoring due to the known cardiotoxicity and delayed onset of life-threatening effects associated with tricyclic antidepressants. The differential diagnosis includes accidental ingestion, but the psychosocial background and circumstantial evidence favor a diagnosis of deliberate self-poisoning.
Plan
Immediate medical management included airway protection and administration of intravenous fluids to stabilize blood pressure. Activated charcoal was administered within the first hour of emergency arrival due to the uncertain timing of ingestion. Continuous cardiac monitoring was initiated to watch for QRS prolongation or arrhythmias, common with tricyclic antidepressant toxicity. Sodium bicarbonate therapy was considered for potential cardiotoxic effects. A psychiatric consultation was requested to evaluate the patient’s mental health status and risk of future self-harm. Serial blood work and toxicology screens were planned every six hours to monitor drug levels and organ function. The patient was admitted to the intensive care unit for 24-hour observation with possible transfer to a psychiatric facility upon stabilization. The importance of family support and mental health follow-up was emphasized as part of long-term recovery and prevention strategy.
Conclusion
This SOAP note example illustrates the comprehensive and methodical documentation approach required in poisoning cases. By breaking down the patient’s presentation into Subjective, Objective, Assessment, and Plan sections, healthcare professionals can ensure a clear understanding of the clinical situation, facilitate interdisciplinary communication, and guide targeted interventions. In toxicology and poison control cases, the structured SOAP note not only improves patient safety but also contributes to legal documentation and future care planning. Employing a precise and detailed documentation format such as this is essential in managing complex poisoning cases effectively and efficiently.
