Problem-Focused SOAP Note week 3

Use the format below for your SOAP note.

Use the current APA format to style your paper and cite your sources. Review the rubric for more information on how your assignment will be graded.

Problem-focused SOAP Note Format

Demographic Data

• Age, and gender (must be HIPAA compliant)

Subjective

• Chief Complaint (CC): A short statement about why they are there • History of Present Illness (HPI): Write your HPI in paragraph form. Start with the age,

gender, and why they are there (example: 23-year-old female here for…). Elaborate using the acronym OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment

• Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance

• Family Hx: any history of CA, DM, HTN, MI, CVA? • Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc. • Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap,

vaccines, colonoscopy)

Objective

• Vital Signs • Physical findings listed by body systems, not paragraph form- Highlight abnormal findings

Assessment (the diagnosis)

• At least Two (2) differential diagnoses (if applicable) with rationale and pertinent positives and negatives for each

• Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological explanation

Plan

• Dx Plan (lab, x-ray) • Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and

refill(s) (if any) • Pt. Education, including specific medication teaching points • Referral/Follow-up

 

 

• Health maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next due

Reference

• Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly.