In medical documentation, the SOAP note format—Subjective, Objective, Assessment, and Plan—serves as a critical tool for capturing patient encounters. When addressing poisoning cases, particularly in emergency settings, the clarity and detail provided in SOAP notes are vital for diagnosis, treatment, and follow-up. This article offers a fully structured SOAP note example poisoning case, SEO-optimized example of a SOAP note tailored to a poisoning case, reflecting real-world application for healthcare professionals, students, and toxicology specialists.
Subjective
A 29-year-old male presents to the emergency department with complaints of dizziness, nausea, and vomiting that began two hours prior. The patient reports that he ingested an unknown quantity of acetaminophen tablets in a suicide attempt following a recent emotional crisis. He admits to taking approximately 30 extra-strength tablets (500 mg each), totaling an estimated dose of 15,000 mg. The ingestion occurred at approximately 6:30 PM. He began feeling nauseous and fatigued about an hour later. The patient denies any prior history of suicide attempts or chronic liver disease but confirms he has been experiencing depressive symptoms for several weeks. He is otherwise healthy, with no known drug allergies, and has not taken any other substances, prescription or illicit. He lives alone and was brought in by a friend who found him disoriented and vomiting.
Objective
Upon arrival, the patient appears pale and diaphoretic. Vital signs are as follows: Temperature 98.6°F, Heart Rate 110 bpm, Respiratory Rate 20 breaths per minute, Blood Pressure 132/84 mmHg, and Oxygen Saturation 97% on room air. Physical examination reveals mild abdominal tenderness, particularly in the right upper quadrant. Neurological examination is non-focal, and the patient is alert but tearful. Laboratory tests were promptly ordered. Initial labs show elevated AST and ALT levels, suggestive of early hepatocellular injury. Serum acetaminophen concentration, drawn approximately two and a half hours post-ingestion, is elevated and places the patient above the treatment line on the Rumack-Matthew nomogram. Complete blood count and renal function tests are within normal limits. Electrocardiogram reveals sinus tachycardia without any abnormalities. The toxicology screen is negative for other substances.
Assessment
Acute acetaminophen poisoning with a high risk for hepatotoxicity. Based on the estimated dose ingested and the lab-confirmed serum concentration, this case qualifies as a medical emergency requiring immediate antidotal therapy. The absence of co-ingestants and the timing of presentation (within the optimal treatment window) increase the likelihood of a favorable prognosis if treatment is initiated promptly. The emotional context and suicidal intent also necessitate psychiatric evaluation following stabilization.
Plan
- Begin intravenous N-acetylcysteine (NAC) protocol immediately as per hospital guidelines for acetaminophen overdose.
- Admit the patient to the medical observation unit for serial liver function tests and continued monitoring of vital signs and mental status.
- Continue IV hydration to support renal function and facilitate toxin clearance.
- Consult psychiatry for suicide risk assessment and to initiate a mental health support plan.
- Notify the poison control center for case documentation and follow-up recommendations.
- Educate the patient about the dangers of acetaminophen overdose and the importance of mental health treatment.
- Family contact and involvement will be considered once the patient stabilizes to support future outpatient care and adherence to psychiatric follow-up.
This SOAP note example illustrates a realistic poisoning case while emphasizing the importance of accurate and structured documentation. In medical practice, especially toxicology and emergency medicine, SOAP notes not only guide care but also serve as legal and educational records. By using a clear and consistent format, healthcare providers can ensure all critical information is conveyed effectively across interdisciplinary teams.
In poisoning cases, rapid identification, assessment, and intervention can mean the difference between life and death. The use of the SOAP note framework helps ensure that care is both efficient and comprehensive. This format also plays a significant role in streamlining communication during patient handoffs, legal inquiries, or quality improvement reviews.
Clinicians, nurses, medical students, and poison control professionals should familiarize themselves with how to adapt the SOAP note to toxicological emergencies. Each section plays a unique role—from capturing the patient’s story and clinical symptoms to forming a diagnostic impression and laying out a treatment roadmap. As demonstrated in this example, careful attention to subjective details, timely objective data collection, a well-reasoned assessment, and an actionable plan can lead to positive patient outcomes even in complex poisoning scenarios.