SOAP NOTE

Directions: Students may use this general SOAP note template or their own. Save a copy to your device to alter the document. Use APA when called for by the rubric or assignment prompt. The APA title page will be the first page, and the template will start on the second page. End with your APA formatted references. Keep in mind this template is structured for an average, problem-focused visit. This template will not be adequate for some special populations and situations (newborns/pregnancy visits/child wellness, etc.). Students need to use good clinical judgment and make additional headings and sections when needed and remove others as applies.

Consider viewing the EMS documentation guidelines from the US Department of Health and Human Services/CMS:

Delete all text in red – these are instructions and not part of the SOAP document.

Student Name and clinical course: (If no title page):______________________

ID:

Clients Initials*:_______Age_____ Race__________Gender____________Date of Birth___________

Insurance _______________ Marital Status_____________

*It is recommended to include false initials and use Jan 1, XXXX (correct year) to protect client confidentiality. Include brief statement on whether the patient came to the clinic alone or accompanied, and if so by whom, and whether they are a reliable historian.

Subjective:

CC: A few words, a sentence or less. Indicate who provided information about the symptoms. Example: Patient reported that Ive had a cough and sore throat for 2 days

HPI:

In paragraph format, including at the minimum OLDCARTS. Please start with demographics: AA, a 29 y.o. Asian female presents to the clinic alone with complaint of _____________.

Onset, Location, Duration, Characteristics/context, Aggravating factors or Associated symptoms, Relieving Factors, Treatment, and Timing, Severity. Include any pertinent positives or negatives.

Medications: include name, dose, frequency, and route. Include PRN medications and how often they are taken.

Past Medical History:

Medical problem list: details on past and present illnesses, be careful not to blindly copy from prior clinical notes

Preventative care: (if applicable to the case – Paps, mammography, colonoscopy, dates of last visits, etc.)

Surgeries: past surgeries and rough dates when possible

Hospitalizations: past hospitalizations with reason for admit, duration of stay, and rough dates

LMP, pregnancy status, menopause, etc. for women

Allergies:

Food, drug, environmental: list medications and food allergies, specify type of reaction

Family History: go back 2 generation indicate if alive, deceased, or unknown. details on family members, their age, and illnesses/conditions.

Social History:

-Sexual history and contraception/protection (as applies to the case)

-Chemical history (tobacco/alcohol/drugs) (ask every pt about tobacco use)

Other: -Other social history as applicable to each case (diet/exercise, spirituality, school/work, living arrangements, developmental history, birth history, breastfeeding, ADLs, advanced directives, etc. Exercise your critical thinking here – what is pertinent and necessary for safe and holistic care)

ROS (write out by system): Comprehensive (>10) ROS systems for wellness exams or complex cases only. Do not include diagnoses – those belong in PMH. Include only subjective data which patient reports or denies. Do not include any objective data which should go under physical examination. The below categories are per CMS guidelines.

Constitutional:

Eyes:

Ears/Nose/Mouth/Throat:

Cardiovascular:

Pulmonary:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Integumentary & breast:

Neurological:

Psychiatric:

Endocrine:

Hematologic/Lymphatic:

Allergic/Immunologic:

Objective

Vital Signs: HR BP Temp RR SpO2 Pain

Height Weight BMI (be sure to include percentiles for peds)

Labs, radiology or other pertinent studies: be sure to include the date of labs – might be POC tests from today

Physical Exam (write out by system):

Start with a General survey:

Skin:

HEENT (Head, Eyes, Ears, Nose, Throat):

Neck:

Cardiovascular (Heart):

Respiratory (Lungs):

Abdomen:

Back:

Rectal:

Extremities:

Musculoskeletal:

Neurologic:

Psychiatric:

Pelvic:

Breast:

Genitourinary (G/U):

Assessment

(you will often have more than one diagnosis/problem, but do the differential on the main problem, Support diagnoses with evidence-based references.)

Differentials (with a brief rationale for each):

1.

2.

3.

Diagnosis (may have more than one, include ICD-10 if rubric or as your instructor specifies)

Plan (4 pronged plan for each problem on the problem list, Support plans with national guidelines or evidence-based references.)

Diagnostics:

Treatment:

Education

Follow Up:

Reference