Description
Use following template and make up the information. The chief complaint is “I have a really bad headache that feels like pressure and radiates to my ear”Diagnosis – Sinus infection Please make up everything else and use the template exactly like it is.
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WCU Adult Gero SOAP Note Template
Use this template for Comprehensive Notes (Initial Comprehensive/Annual visit) and
Problem-Focused Notes (Episodic/progress notes). For the Problem-Focused Notes, only
include pertinent problem-focused information related to the chief concern (CC).
Demographic Data
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Patient age and gender identity
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MUST BE HIPAA compliant
Subjective
Chief Complaint (CC)
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Place the complaint in Quotes
Brief description -only a few words and in the patient’s words
Example: “My chest hurts,” “I cannot breath,” or “I passed out,” etc.
History of Present Illness (HPI) – the reason for the appointment today
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Use the OLDCARTS acronym to document the eight elements of a chief concern
(CC): Onset, Location/radiation, Duration, Character, Aggravating
factors, Relieving factors, Timing, and Severity
Briefly describe the general state of health prior to the problem.
Past Medical History:
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List current and past medical diagnoses (in list format)
Past Surgical History:
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List all past surgeries including dates (in list format)
FAMILY HISTORY:
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Include medical/psychiatric problems to include 2 generations (parents, grandparents,
siblings, or direct relatives (in list format).
Current Medications:
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Include current prescription(s), over-the-counter medications, herbal/alternative
medications as well as vitamin/supplement use.
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Include Name of medication, Dosage, Route, frequency.
ALLERGIES:
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Include medications, foods, and chemicals such as latex.
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Include reaction type in parenthesis.
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Example: Penicillin (Hives)
Immunizations History: list current immunization status and address deficiency
health maintenance: (See Table below – Appendix A)
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List any age appropriate health maintenance due/recommended in list format.
SOCIAL HISTORY:
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An acronym that may be used here is HEADSS which stands for Home and
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Environment; Education, Employment, Eating; Activities; Drugs/Alcohol;
Sexuality.
Employment/Education should include: occupation (type), exposure to harmful
agents, highest school achievement
REVIEW OF SYSTEMS:
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A ROS is a question-seeking inventory by body systems to identify signs and/or
symptoms that the patient may be experiencing or has experienced that may or
may not correlate with the CC.
*If a + finding is found not related to the cc this may represent an additional
problem that will need to be detailed in the HPI.
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Must include any physical complaint(s) by the body system that is relevant to the
treatment and management of the current concern(s). List only the pertinent
body systems specific to the CC.
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Remember to include pertinent positive and negative findings when detailing the
ROS related to a chief concern (cc).
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Pertinent positives should be documented first.
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Do not repeat the information provided in HPI
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Documented as “Reports” or “Denies”
Example of an exemplary negative ROS for a Comprehensive Note.
General: Denies malaise, weakness, fever, or chills. Denies recent weight gains or losses
of >20 pounds over the last 6 months.
Eyes: Denies change in vision or loss of vision, eye pain, sensitivity, or discharge.
Ears, nose, mouth & throat: Denies ear pain, loss of or decreased hearing, ringing of the
ears, drainage from the ears. Denies change in sense of smell, nose bleeds, sinus or facial
pain, speaking problems, hoarseness or choking, dry mouth, dental problems, or difficulty
chewing or swallowing.
Cardiovascular: Denies chest discomfort, heaviness, or tightness. Denies abnormal
heartbeat or palpitations. Denies shortness of breath, denies having to sleep elevated on 2
pillows or more, no swelling of the feet, no passing out or nearly passing out. Denies
history of heart attack or heart failure.
Respiratory: Denies cough, phlegm production, coughing up blood, wheezing, sleep
apnea, exposure to inhaled substances in the workplace or home, no known exposure to
TB or travel outside the country. Denies history of asthma, COPD/emphysema or any
other chronic pulmonary disease.
Gastrointestinal: Denies nausea, vomiting, abdominal discomfort/pain. Denies diarrhea,
constipation, blood in the stool or black stools. Denies hemorrhoids, trouble swallowing,
heartburn or food intolerance. Denies history of liver or gallbladder disease. No recent
weight gains or losses of > 20 pounds within the last year.
Skin & Breasts: Denies rash, itching, abnormal skin, or recent injury. Denies breast pain,
discharge, or other abnormality was reported by the patient.
Musculoskeletal: Denies muscle or joint pain, back or neck pain, and denies recent
accidents or injuries. Denies physical disability or condition that limits activity or ADLs.
Allergic: Denies history of seasonal allergies, allergic rhinitis, watery eyes, or wheezing.
Denies history of HIV, hepatitis, shingles, or recurrent infections
Immunologic: Denies history of HIV, TB, hepatitis, shingles, or other recurrent infectious
diseases. Denies history of cancer – radiation or chemotherapy.
Endocrine: Denies polyuria, polydipsia, and polyphagia. Denies history of blood sugar
instability. Denies temperature intolerance to hot or cold. Denies swelling of the neck or
nodules.
Hematopoietic/Lymphatic: Denies unusual lumps or masses. Denies bruising quickly or
bleeding easily. Denies history of anemia or recent blood transfusions. Denies sickle cell
disease or trait. Denies blood dyscrasias.
Genitourinary: Denies dysuria, frequency, or urgency. Denies abnormal vaginal/penile
discharge or bleeding. Denies recent history of bladder or kidney infections/stones.
Denies sexual dysfunction or concerns.
Neurological: Denies unusual headaches, history of head injury or loss of consciousness,
lightheadedness, dizziness, vertigo. Denies numbness of a body part or weakness on one
side of the body. Denies pins and needle sensation, abnormal movements, or seizure
disorder. Denies previous strokes, seizures or neurological disorders.
Psychiatric/Mental Status: Denies history of depression or anxiety. Denies difficulty
sleeping, persistent thoughts or worries, decrease in sexual desire, abnormal thoughts,
visual or auditory hallucinations. Denies history of psychosis or schizophrenia. Denies
difficulty concentrating or change in memory.
Objective
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure. Heart rate. Respirations. SaO2 (on room air or O2).
Temperature. Weight. Height. BMI.
Example of exemplar PE for a Comprehensive Note with no abnormal findings.
CONSTITUTIONAL/general appearance: Vital signs stable, in no acute distress. Alert, well
developed, well nourished.
HEENT:
Head: Atraumatic, normocephalic.
Eyes: Sclerae were white. Conjunctivae and lashes were clear. No lid lag. Extraocular
movements were intact (EOMI). PERRLA.
ENT: Ears, nose, mouth, and throat: Mucous membranes were pink, moist and intact.
External ear canals were clear without cerumen. TMs were clear, pearly gray with good light
reflex bilaterally. Hearing was intact to whisper. Nares patent and mucosa is pink, moist and
intact. Mouth, lips and tongue, gums were intact with no lesions. Good dentition. Hard and
soft palates intact. Tongue and uvula midline.
NECK: Supple. No JVD, thyromegaly or lymphadenopathy.
RESPIRATORY/CHEST: Unlabored. Chest rise is equal and symmetric. Lungs are CTA
bilaterally with no adventitious breath sounds.
CARDIOVASCULAR: S1, S2 without murmurs, rubs or gallops appreciated.
Breasts: Skin intact without lesions, masses, or rashes. No nipple discharge. Breasts with
slight asymmetry, no dimpling, retractions or peau d’orange appearance.
GI: Normoactive bowel sounds. No hepatosplenomegaly on exam. No tenderness, masses,
or hernias appreciated.
Genital/rectal: no suprapubic tenderness or bladder bulges. No lesions, rashes, masses or
swelling.
Lymph nodes: No enlarged glands of the neck, axilla or groin.
MUSCULOSKELETAL: Gait and station were within normal limits. Full range of motion
in all joints. Muscle strength and tone were 5/5 all groups. Equal arm swing.
INTEGUMENTARY: Skin was warm and intact. No rashes, lesions, masses or
discoloration. No abnormalities to fingers or toenails noted.
EXTREMITIES: No cyanosis or clubbing. No edema of the extremities. Pulses +2
bilaterally radial and pedal.
Neuro: Cranial nerves are intact grossly, II-XII. DTRs intact, +2 bilaterally with symmetric
response. Sensation intact to light touch. No motor or sensory deficits.
PSYCH: A&O x3. Recent and remote memory intact. Mood and affect appropriate during
visit. Judgment and insight were within normal limits at the time of visit.
*Full mini-mental status exam may be indicated based on the CC or findings in the ROS or
physical exam.
Assessment (Diagnosis)
Differential Diagnosis (DDx)
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Include two (2) differential diagnoses you considered but did not select as the
final diagnosis. Why were these 2 diagnoses not selected? Support with pertinent
positive and negative findings for each differential with an evidence-based
guideline(s) (required).
Working or Final Diagnosis:
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Final or working diagnosis (1) (including ICD-10 code)
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Provide a rational explanation supported by evidenced-based guidelines
(required). List the pertinent positive and negative symptoms/signs that support
your final diagnosis.
Plan
Treatment (Tx) Plan: pharmacologic and/or nonpharmacologic
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Diagnostics. Any labs, imaging, ordered? Remember you are managing this
patient in the outpatient/clinic setting, not the hospital.
Pharmacologic -include full prescribing information for each medication(s)
ordered. Name of Medication, Dosage, Route, Frequency, Duration, number of
tabs prescribed, number of refills.
Patient Education:
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include specific education related to each medication prescribed.
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Was risk versus benefit of current treatment plan addressed for medication(s) and
interventions? Was the patient included in the medical decision making and in
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agreement with the final plan?
NPs should not be prescribing non-FDA approved medications or medications
related to off-label use. If a physician prescribed a non-FDA-approved medication
for working diagnosis or recommended off-label use, was education provided and
was the risk to benefit of the medication(s) addressed in the patient’s education?
Referral/Follow-up
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When would you like the patient to be seen in clinic again. Did you recommend
follow-up with PCP, or other healthcare professionals/specialists?
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When is the subsequent follow-up?
Reference(s)
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Include APA formatted references for written assignments.
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Minimum 2 references are required from evidence-based resources.
APPENDIX A
Health Maintenance (Example – not all-inclusive)
Preventive Care
Pap
Mammogram
A1C
Eye Exam
Monofilament Test
Urine
Microalbumin
Diet/Lifestyle Changes
Digital Rectal Exam (DRE)
PSA
Colonoscopy or FOBT
Dexa Scan
CXR
BNP
ECG
Echo
Stress
Test
Vaccines
The Prevention TaskForce (formerly ePSS) application assists primary care
clinicians to identify the screening, counseling, and preventive medication services
that are appropriate for their patients.
Download this app and be sure to reference when assessing Health Maintenance
priorities for your patients:
https://www.uspreventiveservicestaskforce.org/apps/
Purchase answer to see full
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