NUR 634 SOAP Note Guide and Template

Patient SOAP Note Charting Procedures

S = Subjective

O = Objective

A = Assessment

P = Plan

Subjective: Information the patient tells the treating team or patient advocate. Symptoms, not signs. These are typically not measurable, such as pain, nausea, and tingling, hence the term “subjective” as opposed to “objective”. Normally, the practitioner is not aware of this information until the patient provides it.

Objective: Information gathered by the treating team or provider which is typically observable and measurable, hence “objective” as opposed to “subjective”. Normally, the patient is not aware of this information until the practitioner elicits it. This might include, for example, ranges of motion, body temperature, blood pressure, the presence of a skin rash or wound, comments about the patient’s posture or gait, and the results of examination procedures and testing.

Assessment: The diagnosis. This must be documented prior to the rendering or delivery of any treatment. Symptom code can be documented as assessment when pending final diagnosis such as Chest pain vs. MI.

Plan: Based on the assessment or diagnosis, the treatment or therapeutic plan must be outlined. This may include both short and long term plans. It is important to record not only passive therapy, such as an injection, a prescription, a spinal manipulation or a massage, but also active therapy such as home care advice, exercises or other recommendations. All treatment planned or delivered must be recorded.

SOAP NOTE TEMPLATE

**Please delete the instructions in each section prior to submitting the assignment

Student Name: Date: Course:

Subjective:

Patient Demographics: (age, gender, gender identity, ethnicity, etc.)

Chief Complaint: “quote patient”

History of Present illness: (Be sure to tell the “story” of the cc using the 7 attributes or OLDCARTS)

PMH: dates in reverse chronological order.

PSH: surgery dates in reverse chronological order.

Allergies: medications, OTCs, supplements, & environmental/seasonal/food allergies

Untoward Medication Reactions: include type of reaction/severity/date

Immunization Status: e.g. Flu, COVID, TdaP, etc.

Screenings: In this section you will document any age-appropriate screenings the patient had prior to the visit today. For example, dental visits, PAP, colorectal screening, microfilament, etc… (Indicate if results were normal or abnormal)

FMH: document genetically relevant conditions of immediate family members (parents, children, siblings, and grandparents). If history is unknown then document “history unknown” for the family member you inquired about.

Personal History/Social History: Occupation, home environment, relationship status, nutrition, exercise, and substance use (smoking, alcohol, illicit drug use)

Females: LMP and relevant OB/GYN history Gravida, Para, Abortions, Living (G__P__A__L__)

If prior pregnancies document any pregnancy or postpartum complications.

Sexual History: #of partners, sex of partner/s, protected/unprotected sexual relations, contraception

Current Medications/OTCs/Supplements: indicate Dose, Route, Frequency (write either class of medication or indications for use in parentheses)

For Episodic Visit, only list ROS/PE that are pertinent to CC/HPI. Complete a full ROS for a comprehensive/well exam visit.

Review of Systems:

General:

Skin:

HEENT:

Head:

Eyes:

Ears:

Nose:

Throat:

Breasts:

Respiratory:

Cardiovascular:

Gastrointestinal:

Genitourinary:

Peripheral Vascular:

Musculoskeletal:

Neurologic:

Hematologic:

Lymphatic:

Endocrine:

Psychiatric:

Objective:

For Episodic Visit, only list ROS/PE that are pertinent to CC/HPI. Complete a full PE for a comprehensive/well exam visit.

Physical Exam:

Vital Signs: Blood Pressure- P- RR- T- Height- Weight- BMI-

General:

Skin:

HEENT:

Head:

Eyes:

Ears:

Nose:

Throat:

Neck:

Breasts:

Lungs:

Heart:

Abdomen:

Genitourinary:

Rectal:

Peripheral Vascular:

Lymphatic:

Extremities: Musculoskeletal:

Neurological:

Assessment:

Differential Diagnosis Diagnostic Reasoning Exercise: Minimum of 3 differential diagnoses/maximum of 5 differentials—the table will help with the narrative write-up required below the table.

In a narrative format explain how you arrived at your final diagnosis or working diagnoses based on the CC/HPI, PMH, PSH, ROS, & Physical Exam (pertinent +/– will guide this process). This should be written using examples of how the history/clinical presentation led to the final diagnosis or working diagnosis (APA citations to your references must be included – use resources with Evidence Based Guidelines)

Plan:

Include a brief summary of the visit here

(APA citations required in your plan)

In this section, you would list the diagnosis that you assessed for your patient. The Diagnosis is your primary/working diagnosis made at the time of the visit. If you have not made a diagnosis, then you would use the ICD-10 code for the symptomatology since r/o diagnoses are not billable. This should be followed by a plan of care that is evidenced based.

Diagnosis ICD-10 (must be related to CC/HPI)

· Treatment

· Lab/test

· Referral

· Education

· Follow up