Chapter 8 – The SOC Checklist in SOAP Format

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Below is a sample checklist in SOAP format for gathering OASIS data that I personally use which I have customized for my needs. I bring this checklist with me every patient visit and go through this checklist every time so that I do not miss anything.

According to the book Checklist Manifesto: How to Get Things Right by Atul Gawande, checklists are great for improving job performance in the workplace. In my personal experience, having a comprehensive checklist puts me at ease and reduces my anxiety knowing that I have a reference and guide to all things I need to cover during the day.

But be warned that as you go through the process of referencing your checklist day to day, you may notice that after a few weeks or after a few months of using the checklist daily, you start getting into a habit and the checklist starts becoming a mental checklist for you.

Be careful when the physical checklist starts becoming a mental checklist, so that you do not become prideful and start making mistakes. Relying on a mental checklist is a recipe for disaster, as the human mind is prone to error. Always rely on a physical copy of a checklist, whether on paper or digitally, to do your job right.

Let this template be a guide for you to create your own checklist as you see fit, or use this checklist as is for your own practice.

Comprehensive SOC Checklist:

Patient Name:                                      Date:                    MD/DO:                       Reason for Visit: SOC, ROC, Recert, F/U, DC                          

From: Community/Hospital/SNF                 DC Date:                     LOS:                           Reason for referral (CC):PMHx:                                                         PSHx:HPI (OLDCART):                                                              Diabetes, PAD, or PVD?IV Access Y/N                    Oral: indep/setup/reminder/unable/NA                   Injectable: indep/setup/reminder/unable/NAMedications (MED LIST):                       
Drug Issues:              Allergies:       
Limitations: Amputation, Dyspnea, Paralysis, Contracture, Blind, Incontinent, Hearing, Endurance, Speech Lives: Alone, w/Someone, ALF Assistance Available: Around Clock, Day, Night, Short Term, None ///  PCG name & contact:                       Community/Social Screening: Needs resources, Sadness, Suicidal, Suspected Abuse/Neglect For:         MSW Needed: Y/NHome Safety: Stairs, No running water; poor lighting, heat, or cool; narrow or obstructed walkways, insects/rodents, no fire safety, cluttered/soiled, Other:
O2 Safety Y/N: NA, No Smoking Signs, Smoke inside, Smoke Detectors, Fire Extinguisher, Safe Cylinder Storage, Cords Intact, Evacuation Plan, Cleaning Fluids, No petroleum products, Only water-based lip moisturizers
Pain:                             Code Status: DNR/Full code            Adv Directives:               Vaccines: Flu, Pneumonia, Shingles, TB

VS: BP:           PP:         Temp:          Resp:         O2:                            Ht:      Wt:                           BS:                 Labs (if any):
HEAD TO TOE ASSESSMENT/REVIEW OF SYSTEMS:Sensory: Eyes/Vision: Poor vision? Y/N       Ears: HOH? Y/N         Nose: Nasal obstruction? Y/N  Neuro: Oriented: Person Place Time, Disoriented, Forgetful, PERRL, Seizures, TremorsPsychosocial: Poor Environment, Poor Coping, Agitated, Depressed, Impaired Decision-Making, Anxiety, Inappropriate Behavior, Irritability              PHQ-2: Last two weeks, Little interest or pleasure in doing things? Feeling Down, depressed, or hopelessLungs: SOB, Supplemental O2, O2 Sat, Cough,      Auscultation lung fields:    Adventitious lung sounds? Y/NCardiac: Chest Pain, Dizziness, Edema, Heart Sounds, Peripheral Pulses,      Cap Refill <3, >3       Pacemaker. AICDBowels: Incontinen Freq      Ostomy:      Dialysis Hemo, Graft/Fistula Site:    CVC Site:    Peritoneal             Signs of infection Y/NNutrition: Dysphagia, Poor Appetite, Wt Loss/Gain: Diet: Adequate Y/N  Problems: Throat, Dental, Dentures, Chewing, Other:Urinary: Incontinence, Distention, Burning, Frequency, Dysuria, Retention, Urgency, Urostomy    Catheter Last Changed:       Cloudy, Odorous, Sediment, Hematuria      Genitalia:Skin: Wounds:Diabetes: Insulin, pt/cg draw dose/administer, oral hypoglycemic, pt/cg indep with glucometer, inspect feet       Blood Sugar:Other Endocrine: Polyuria, Polydipsia, Polyphagia, Neuropathy, Radiculopathy, Retinopathy  // Thyroid Problems:Musculoskeletal: WNL Weakness Amb Difficulty Limited Mobility/ROM Joint Pain/Stiffness Poor Balance Grip Strength R L Bed Bound     Chair Bound Contracture Paralysis          Has Assistive Device/s:Needs DME:ADL/IADLs: Activities Permitted: Bed Rest Cane Partial Weight Bearing Up as tolerated Walker Crutches Exercise Prescribed Wheelchair                 Indep at Home Transfer bed<>chair            Other:ADLs: Indep/Setup/Assist/Dep/Device Grooming Dress upper Dress Lower Bathing Toilet Transfer Toilet Hygiene Transfers Amb EatingGG Scoring: 6 – Indep 5 – Setup 4 – Sup/touch 3 – Partial/Mod 2 – Substantial/Max 1 – Dep 7 – Refused 9 – NA 10/88 – No attempt enviro/safetyGG Questions: Self Care Eating Oral Hygiene Shower Self Dress Upper Dress Lower Don/Doff FootwearMobility Roll Sit>Lying Lying>Sit Sit>Stand Chair<>Bed Toilet Transfer Car Transfer Walk 10 50 (+2 turns) 150    Steps 1 4 12 Pick up object WC Assist 50 150 (+2 turns)
ANursing Diagnosis:                                                           Possible New Medical Diagnosis (if any):Additional Notes:
PNursing Intervention:                                                 Consents/RS Signed: Y/N               HHA Agency contact info given: Y/NDisciplines Needed: PT/OT/ST/SN/MSW, AideNext Physician Visit:Pharmacy name and phone:

I also use a variation of the above comprehensive checklist which has been further simplified, to include just the basics. This shorter checklist serves as a simpler guide when visiting multiple patients and you have had more experience knowing what data can be gathered easily and which data may need more effort and attention to gather. It also fits into just one page.

Simple Checklist:

Patient Name:                             Date:                                               MD/DO:                       Reason for Visit: SOC, ROC, Recert, F/U, DC                          

Recent hospitalization date (if any):                                             Primary Dx:                                                       Therapies pt receives at home: (IV, parenteral, NG, GT, O2, etc)Advanced directive – yes, no, DNRPt Living Situation: (alone, w others,)Medications (MED LIST):    Allergies:  Vaccines: Flu, Pneumonia, Shingles, TBPCG name & contact: 

VITALS/PAIN – bp, hr, temp, rr, O2sat, *painHt:      Wt:                   BS:             
SYSTEMS ASSESSMENT:eyes, ears, noseskin, pressure ulcer, woundslung sounds, SOB, O2DM?, thyroid?Heart sound, rhythm, pulse, edema, pacemakerLast BM, GI probs, foley, ostomy, dialsDiet, weight loss, eating well?LOC, depression screen, sleeping well?Mobility, DME needs, recent falls?
ASignificant finding(s) to report:
PNursing Intervention:                                                 Consents/RS Signed: Y/N               HHA contact info given: Y/NDisciplines Needed: PT/OT/ST/SN/MSW, AideNext Physician Visit:Pharmacy name and phone:

Where to Download

To download either of these checklists, go to 

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