Description
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.
Unformatted Attachment Preview
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
o
o
Patient age and gender identity
MUST BE HIPAA compliant
Subjective
Chief Complaint (CC)
O
O
O
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
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
O Briefly describe the general state of health prior to the problem.
O
PAST MEDICAL HISTORY:
O List current and past medical diagnoses (in list format)
PAST SURGICAL HISTORY:
O List all past surgeries including dates (in list format)
FAMILY HISTORY:
O Include medical/psychiatric problems to include 2 generations (parents,
grandparents, siblings, or direct relatives (in list format).
CURRENT MEDICATIONS:
O Include current prescription(s), over-the-counter medications,
herbal/alternative medications as well as vitamin/supplement use.
O Include Name of medication, Dosage, Route, frequency.
ALLERGIES:
O Include medications, foods, and chemicals such as latex.
O Include reaction type in parenthesis.
O Example: Penicillin (Hives)
IMMUNIZATIONS HISTORY: list current immunization status and address
deficiency
HEALTH MAINTENANCE: (See Table below – Appendix A)
o List any age appropriate health maintenance due/recommended in list
format.
SOCIAL HISTORY:
An acronym that may be used here is HEADSS which stands for Home
and Environment; Education, Employment, Eating; Activities;
Drugs/Alcohol; Sexuality.
O Employment/Education should include: occupation (type), exposure
to harmful agents, highest school achievement
O
REVIEW OF SYSTEMS:
O 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.
O 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.
O Remember to include pertinent positive and negative findings when
detailing the ROS related to a chief concern (cc).
O Pertinent positives should be documented first.
O Do not repeat the information provided in HPI
O 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)
O
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:
O Final or working diagnosis (1) (including ICD-10 code)
O 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
Diagnostics. Any labs, imaging, ordered? Remember you are managing
this patient in the outpatient/clinic setting, not the hospital.
O Pharmacologic -include full prescribing information for each
medication(s) ordered. Name of Medication, Dosage, Route, Frequency,
Duration, number of tabs prescribed, number of refills.
O
Patient Education:
O include specific education related to each medication prescribed.
O 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 agreement with the final plan?
O NPs should not be prescribing non-FDA approved medications or
medications related to off-label use. If a physician prescribed a nonFDA-approved medication for working diagnosis or recommended offlabel use, was education provided and was the risk to benefit of the
medication(s) addressed in the patient’s education?
Referral/Follow-up
O When would you like the patient to be seen in clinic again. Did you
recommend follow-up with PCP, or other healthcare
professionals/specialists?
O When is the subsequent follow-up?
Reference(s)
o Include APA formatted references for written assignments.
o 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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