Accurate documentation plays a vital role in managing toxic exposures. A SOAP note example poisoning case offers healthcare providers a structured way to evaluate, treat, and follow up on poisoning incidents. The SOAP format—Subjective, Objective, Assessment, and Plan—is widely used in clinical settings to document patient encounters systematically, ensuring no detail is overlooked in high-stakes situations like poisonings.

Let’s explore a realistic SOAP note example poisoning case involving a young child who has accidentally ingested medication. This type of scenario is common in pediatric emergency departments and poison control centers, where precise documentation and prompt decision-making can significantly impact outcomes.

In this SOAP note example poisoning case, a 3-year-old boy is brought to the emergency department by his mother after reportedly ingesting five tablets of her prescribed clonazepam. The child was found near an open pill bottle, and his mother believes the ingestion occurred approximately 20 minutes before arrival.

Subjective: The child’s mother reports that she found her son playing with her medication bottle, which she had briefly left on a coffee table. She estimates that he may have swallowed up to five 0.5 mg tablets of clonazepam. After the incident, he appeared sleepy and unsteady on his feet. No vomiting, seizures, or respiratory issues have been observed so far. The child has no known allergies or chronic medical conditions. Immunizations are up to date.

Objective: Upon arrival, the child is drowsy but arousable. Vital signs are as follows: temperature 36.8°C, heart rate 92 bpm, respiratory rate 20 breaths per minute, blood pressure 98/64 mmHg, oxygen saturation 97% on room air. Pupils are equal and reactive. There are no signs of trauma. Breath sounds are clear. Neurologically, he responds to verbal stimuli but appears lethargic and has slightly impaired coordination. No cyanosis or abnormal movements noted.

Assessment: This SOAP note example poisoning case suggests a likely diagnosis of acute benzodiazepine ingestion with mild central nervous system depression. The child’s symptoms are consistent with clonazepam toxicity, including drowsiness and ataxia. No signs of severe toxicity such as respiratory depression or coma are present at this time. The ingestion appears to be within a potentially harmful range given the child’s age and size.

Plan: The immediate plan includes continuous monitoring in the pediatric observation unit with particular attention to respiratory function, level of consciousness, and hemodynamic stability. Activated charcoal is not indicated as the child is not alert enough to protect his airway, and the ingestion occurred more than 15 minutes ago. The poison control center has been consulted and concurs with supportive care as the primary approach. Intravenous fluids will be administered as needed. If respiratory depression develops, flumazenil will be considered with caution due to the risk of seizures. Parents are advised about the potential for delayed effects, and the importance of safe medication storage is reviewed. If the child remains stable, discharge with follow-up may be considered after a 6 to 8-hour observation period.

This SOAP note example poisoning case demonstrates how clear, structured documentation supports safe and effective treatment. By organizing information into the SOAP framework, clinicians can quickly assess the patient’s status, track changes over time, and communicate accurately with other healthcare professionals.

In addition to supporting immediate clinical care, a well-written SOAP note provides essential data for legal records, billing, and quality assurance. In poisoning cases, where outcomes can shift quickly, having a thorough record is crucial. Poison control centers and emergency providers rely on such documentation for real-time collaboration and for learning from case reviews.

Using a SOAP note example poisoning case for training or reference helps reinforce best practices in toxicology and emergency care. It emphasizes the value of timely, detailed, and organized notes in managing complex or potentially life-threatening situations. With consistent use of this format, healthcare providers can deliver high-quality care and ensure accountability at every stage of the patient journey.