Nephrology Progress Note (SOAP)

Date/Time: [Date and time of documentation]

Encounter Setting: [inpatient unit and hospital day / outpatient clinic / telehealth]

Author/Service: [Author name, role, nephrology service]

Primary Team/Referring Clinician: [Team or clinician name]

Subjective

Chief Concern: [Nephrology reason for encounter] (One concise line stating the reason for nephrology follow-up.)

Interval History: [Brief interval changes since last nephrology note] (Prioritize interval changes over static history. Include kidney-relevant events, volume/uremic symptoms, medication changes or nephrotoxin exposures, and diet/fluid adherence issues. For dialysis patients, include session tolerance and access concerns. Explicitly state when there are no interval events of concern. Do not infer symptom absence; only document explicit denials.)

Objective

Vitals/Volume Data: [BP, HR, weight with trend; for inpatients: net I/O and urine output] (Note if I/O data are unavailable or unreliable.)

Exam: [Focused exam emphasizing volume status: JVP, edema, pulmonary exam, mucous membranes] (For dialysis patients, include access exam. If exam not performed, state reason. Conclude with volume status impression: hypovolemic, euvolemic, or hypervolemic with brief supporting rationale.)

Labs/Data: [Creatinine trend anchored to baseline and dates, key electrolytes with trajectories, relevant urine studies, pertinent imaging/procedure results] (Always present creatinine as a trajectory, e.g., "Cr: 1.2 baseline → 1.8 (1/12) → 2.1 (1/13)". Omit labs not relevant to active problems.)

Assessment

Summary: [One to two sentence synthesis of renal status, key driver of current issues, and trajectory]

Problem List: (Order by acuity. Use clear diagnostic labels with KDIGO staging when supported by data. If staging criteria are not met or chronicity is uncertain, document that uncertainty.)

1. [Problem with diagnostic label and stage if applicable]
2. [Additional problems as applicable]

Plan

(For each problem, document concisely: current status/trajectory, suspected etiology or differential if uncertain, and specific plan elements. Address kidney-relevant medications, nephrotoxin management, and renal dose adjustments. Dialysis-specific details appear only when applicable.)

[Problem 1]

[Status/trajectory with supporting data, etiology if uncertain, and plan including diagnostics, therapeutics, monitoring targets, and follow-up timing] (Group related issues together. Include RRT details only if patient is on or being evaluated for dialysis.)

[Problem 2]

[Status/trajectory with supporting data, etiology if uncertain, and plan including diagnostics, therapeutics, monitoring targets, and follow-up timing]

Communication: [Recommendations requiring action by other teams; key discussions with patient/family] (Include only when applicable.)

Signature: [Name, credentials, nephrology service]