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Asked by 1019sevenise

 

Use the format below for your SOAP note.

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

 

 

Problem-Focused SOAP Note Format

Demographic Data

Patient initial (one initial only), age, and gender must be HIPAA compliant.

Subjective

Chief Complaint (CC)
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
Family Hx
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

Physical findings listed by body systems, not paragraph form

Assessment (the diagnosis)

Three (3) differential diagnosis (if applicable) with rationale
Final diagnosis with rationale and pathophysiological explanation

Plan

Dx Plan (lab, x-ray)
Tx Plan (meds)
Pt. Education, including specific medication teaching points
Referral/Follow-up
Health maintenance (including when screenings, immunizations, etc., are next due):

Reference

Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly.
SCIENCE
HEALTH SCIENCE
NURSING
NURS 682

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