Problem Focused SOAP Note
Complete a problem – focused SOAP note. Please follow the template attached. Case will be provided
Demographic Data
Age, and gender (must be HIPAA compliant)
Subjective
- Chief Complaint (CC) unless an Annual Physical Exam (APE)
History of Present Illness (HPI) in paragraph form (remember 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 as applicable
- Family Hx: As applicable
- 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
- Assessment (Diagnosis/ICD10 Code)
Include all diagnoses that apply for this visit
Plan
- Dx Plan (lab, x-ray)
Tx Plan: (meds)
- Pt. Education, including specific medication teaching points
Referral/Follow-up
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