In clinical toxicology and emergency medicine, accurate and timely documentation is crucial for ensuring effective patient care. The SOAP note—an acronym for Subjective, Objective, Assessment, and Plan—is a widely used format for documenting medical encounters. It is especially useful in poisoning cases, where swift evaluation and intervention can be life-saving SOAP note example poisoning case. Below is a detailed SOAP note example tailored to a poisoning case, serving as a guide for healthcare professionals dealing with toxic exposure incidents.
Subjective
The patient is a 28-year-old male who presents to the emergency department with complaints of nausea, vomiting, dizziness, and abdominal pain. The patient reports ingesting an unknown quantity of acetaminophen tablets approximately six hours prior in a suicide attempt. He admits to taking the pills out of emotional distress but cannot recall the exact number ingested. He denies consuming alcohol or any other substances in combination. The patient’s family brought him in after finding an empty acetaminophen bottle on his nightstand and noticing erratic behavior. No known history of liver disease, though he has a past psychiatric history of depression. He is currently not on any prescribed medication.
Objective
Vital signs on admission: Blood Pressure 112/70 mmHg, Heart Rate 98 bpm, Respiratory Rate 18 breaths/min, Temperature 37.4°C, Oxygen Saturation 98% on room air. The patient is alert but appears anxious and restless. Pupils are equal and reactive to light. Cardiac and respiratory exams are unremarkable. Abdominal exam reveals mild tenderness in the right upper quadrant without rebound or guarding. No jaundice or hepatomegaly noted at this stage. Neurological examination shows normal reflexes and no focal deficits. Laboratory investigations reveal elevated liver function tests with ALT at 380 IU/L and AST at 410 IU/L. Acetaminophen serum level is 180 mcg/mL, which is above the toxic threshold based on the Rumack-Matthew nomogram. INR is 1.4 and serum creatinine is within normal limits.
Assessment
Acute acetaminophen poisoning with elevated liver enzymes and a potentially hepatotoxic serum drug level. The timeline indicates that the ingestion occurred within a treatable window for antidotal therapy. The patient is hemodynamically stable and has no signs of hepatic encephalopathy at this stage. This is a high-risk case due to the amount ingested and delayed presentation. Differential diagnoses considered include viral hepatitis, ischemic liver injury, and co-ingestion of hepatotoxic agents, but these are less likely based on the history and labs. Given the context of deliberate ingestion, a psychiatric evaluation will also be necessary once the patient is medically stable.
Plan
Initiate N-acetylcysteine (NAC) treatment immediately according to established protocol. Continue IV hydration and monitor liver function tests, coagulation profile, renal function, and acetaminophen levels every 6 hours. Admit the patient to a monitored bed for close observation. Repeat liver function tests in 12 hours to assess the progression of hepatotoxicity. Provide antiemetics to control nausea and maintain adequate fluid and electrolyte balance. Consult psychiatry for mental health evaluation and suicide risk assessment. Educate the family on the importance of follow-up and safety measures at home. Discharge planning will involve coordination with psychiatric services and possibly social work, depending on the evaluation outcomes. Follow-up with outpatient liver function tests and mental health support will be arranged post-discharge.
Conclusion
This SOAP note example of an acetaminophen poisoning case outlines a systematic and clinically relevant approach to toxicological emergencies. By documenting subjective symptoms, objective findings, diagnostic assessment, and a treatment plan, the healthcare provider ensures continuity of care and clarity in communication. Poisoning cases often involve multidisciplinary management, and effective SOAP notes can serve as a foundation for collaboration across emergency medicine, toxicology, internal medicine, and psychiatry. Timely administration of antidotes like NAC and careful monitoring can dramatically improve patient outcomes. Furthermore, the inclusion of mental health interventions reinforces a holistic approach, addressing both the immediate medical crisis and the underlying behavioral health issues. Proper documentation not only aids in patient care but also enhances medico-legal safety and clinical auditing processes.
