<— Back to ICU Preceptorship Main Page

Remember SOAP notes from school? This is the A/P part (assessment, plan). A lot of times fresh out of school people are really good at assessing, but not at planning

• A good way to do this is to format your plan in the following way:

  • PROBLEM

    • Etio: ***

    • DATA POINT

    • DATA/PLAN POINT

    • PLAN POINT

• Always have datas first, plans second. So for example, if we had a patient:

  • AKI

    • etio: prerenal from intravascular depletion

    • Continue IV fluids

    • Consult nephrology today

    • Serum creatinine now 2.9

    • 0.5L of UOP so far

• If we break that down and categorize each point, we see:

  • AKI

    • etio: prerenal from intravascular depletion

    • Continue IV fluids (Data/plan)

    • Consult nephrology today (Plan)

    • Serum creatinine now 2.9 (Data)

    • 0.5L of UOP so far (Data)

• You want it to be in the order of Data —> Data/Plan —> Plan; so when you change it around you get:

  • AKI

    • etio: prerenal from intravascular depletion

    • Serum creatinine now 2.9

    • 0.5L UOP so far

    • Continue IV fluids

    • Consult nephrology today

• You can have all plans, but not all datas. You can have as much data as long as it is followed by a plan. You must always have a plan. Think to yourself - “what am I going to do about it?”