Infectious Disease SOAP Note

Note Type: [Consult / Follow-up]

Date of Service: [Date]

Author: [Name, credentials]

Setting: [Inpatient / Outpatient / ED / ICU]

Reason for ID Involvement: [Consult question and requesting service, or follow-up indication with interval since last note]

Clinical Summary: [One line capturing host factors, infectious syndrome, organism if known, and current antimicrobial state] (State uncertainty explicitly if source or organism is unknown.)

Subjective

[Interval history narrative] (Summarize illness timeline with key inflection points; include interval events since last evaluation such as new or recurrent fevers, procedures, line changes, culture results; describe symptom trajectory; document antimicrobial tolerance or adherence. Include host factors—e.g., immunosuppression, prior resistant organisms, prosthetics, indwelling devices—and exposure history—e.g., travel, animal contacts, food risks, occupation—only if relevant to current decisions. Include targeted review of systems only when specific findings change the differential; omit routine ROS.)

Objective

Vitals/Exam: [Temperature trend, hemodynamics, oxygen requirement; ID-relevant exam findings including general appearance, skin/rash, line and drain sites, and pertinent focal findings]

Data: [Pertinent labs with trends and dates; imaging findings relevant to source identification or duration decisions] (Include only values that impact ID decisions.)

Microbiology: [Structured culture review] (For each relevant culture: specimen source, collection date, result status, organism identified or no growth, key susceptibility phenotype with source. Include interpretation as pathogen versus contaminant with brief reasoning. Document relevant negative cultures with number of sets and days held. Note pending studies with expected availability. If no cultures obtained, state this explicitly.)

Assessment & Plan

[Global assessment] (Brief synthesis of infectious syndrome, likely source, organism status, clinical trajectory, and key uncertainties or high-risk concerns.)

[Problem Title — use syndrome/pathogen/source format]

Current status: [Working diagnosis with key host/anatomic factors]

• Diagnostics: [Studies to obtain or pending studies to follow with rationale]
• Antimicrobial plan: [Drug, dose, route, frequency, indication, start date] (For empiric therapy, list targeted organisms/resistance patterns and criteria to narrow or discontinue. For directed therapy, reference susceptibility source.)
• Duration: [Number of days] from [anchor event], estimated end date [Date] (State TBD if anchor event has not yet occurred.)
• De-escalation/IV-to-PO: [Criteria and plan] (Specify triggers such as culture finalization, clinical stability, or source control achieved.)
• Source control: [Actions and timing if indicated] (e.g., line removal, drainage, debridement; include needed consultations.)
• Monitoring: [What to check, frequency, and rationale] (Clinical response markers, agent-specific safety labs, drug levels if applicable.)
• Follow-up: [ID disposition, responsibility for pending results after discharge, return precautions] (Name responsible team/person when possible.)

(Repeat problem section for each additional infectious issue.)

Stewardship Reassessment

• Indication: [Confirmed / Unclear]
• Cultures reviewed: [Yes / No] (Include date reviewed.)
• De-escalation opportunity: [Present / None] (Describe plan or reason not feasible.)
• Stop date documented: [Yes / No / TBD] (If TBD, state what data will set the stop date.)
• IV-to-PO eligibility: [Eligible now / Eligible when criteria met / Not eligible]

OPAT Plan

(Include only if patient will continue IV antimicrobials after discharge.)

• Access: [Type and placement date]
• Regimen: [Drug, dose, route, frequency]
• Lab monitoring: [Labs and frequency, including drug levels if applicable]
• Result oversight: [Who reviews results and acts on abnormalities]
• Follow-up: [Timing and provider; responsibility for pending results]

Signature: [Author name, credentials]

(Omit sections that do not affect current clinical decisions. For missing safety-critical information—microbiology status, duration with anchor event, or monitoring ownership—state explicitly as pending or TBD rather than omitting. Do not document interpretive conclusions without supporting reasoning. Avoid importing unreviewed medication or problem lists.)