Trauma Surgery Inpatient Progress Note (SOAP)

Date/Time: [Date and time of note]

Author: [Name, credentials, role]

Attending: [Name, credentials]

Service: Trauma Surgery

Location: [Unit/bed]

HD: [Hospital day] / POD: [Post-operative day if applicable]

Daily Snapshot: [Age] [sex] s/p [mechanism] with [top 2–4 injuries], [HD#/POD#], [ward/SDU], [stable / improving / worsening]. (Single sentence. Include airway/major support only if present.)

Active Injuries

• [Injury, laterality, anatomic location, grade if applicable] — [acute / post-op / non-op]; [trauma / consultant service]; [restrictions/precautions]
• [Suspected injury] — suspected; [confirmatory plan]
• [Resolved injury] — resolved (List resolved injuries last.)

Subjective

[24-hour interval events: procedures, transfusions, escalations, new fevers, antibiotic changes]

[Patient-reported status: pain control, diet tolerance, bowel/bladder function, mobility/therapy participation]

(If patient cannot provide history, note why and document source. Avoid copy-forwarding unchanged content.)

Objective

Vitals: [T max, HR range, BP range, RR, SpO2 with O2 device/flow]

I/O: [24h intake, output, net balance] (Include only if relevant to management.)

Lines/Tubes/Drains: [Device type — output/status, removal readiness]

Exam: [Pertinent findings by system; GCS/neuro exam if relevant; neurovascular status distal to injuries; incisions/wounds] (Note exam limitations if applicable.)

Data: [Pertinent labs with trends; new imaging with one-line impression; culture results if relevant] (Mark pending studies as pending with expected timing.)

Assessment

[Brief synthesis (2–5 sentences): overall trajectory, status of major injuries/post-op course, active threats or concerns, complications if present] (Use "concern for..." for unverified impressions. Do not restate the full plan.)

Plan

• [Problem 1: Injury or condition] — [one-line status]

  • [Operative vs non-operative strategy]
  • [Today's actions and monitoring]
  • [Activity restrictions; weight-bearing status; spine precautions if applicable]
  • [Repeat imaging with timing if planned]
  • [Consultant recommendations and whether following]

• [Problem 2] — [one-line status]

  • (Repeat structure for each active problem, ordered by severity/acuity.)

Daily Essentials:

• VTE prophylaxis: [agent and dose / held with contraindication]
• Pain/Bowel regimen: [multimodal plan]
• Lines/tubes: [removal targets]
• Nutrition: [diet/route]
• Antibiotics: [indication, agent, start date, planned duration, de-escalation plan] (Include only if on antibiotics.)

Disposition: [Anticipated level of care, likely discharge destination, barriers, follow-up needs] (Include when patient is stabilizing.)