SOAP Note Template Discussion

SOAP Note Template Discussion

SOAP Note Template Discussion

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SOAP NOTE

Name: Date: Time:
Age: Sex:
SUBJECTIVE
CC: 

Reason given by the patient for seeking medical care “in quotes”

 
HPI:  Use OLDCART acronym

Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.

 
Medications: (list with reason for med ) write medicine the same way you write a Rx

 
PMH (list approximate year of Dx of the disease or when surgical procedure performed)

Allergies: 

 

Medication Intolerances:

 

Chronic Illnesses/Major traumas

 

Hospitalizations/Surgeries

 

 
Family History (list immediate family, age, disease, and whether is dead or alive)

Does your mother, father or siblings have any medical or psychiatric illnesses?  Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.

 
Social History

Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana.  Safety status

 
ROS (Start each sentence with words such as “Denies, admits, complains, reports”, do not use the words “No, positive for, negative for”. Do NOT list physical exam findings here. If the body system not assess write “Non-Contributory”
General

 

 Cardiovascular

 
Skin

 

 Respiratory

 
Eyes

 

 Gastrointestinal

 
Ears

 

 Genitourinary/Gynecological

 
Nose/Mouth/Throat

 

 Musculoskeletal

 
Breast

 

 Neurological

 
Heme/Lymph/Endo

 

 Psychiatric

 
OBJECTIVE- this is where you document physical exam findings, do NOT use the word NORMAL to document a finding, and instead explain what normal is. For example, the gait is not normal, the gait is steady. If the body part not assessed then type “Deferred”.
Weight        BMI Temp BP
Height Pulse Resp
General Appearance

 
Skin

 
HEENT

 
Cardiovascular

 
Respiratory

 
Gastrointestinal

 
Breast

 
Genitourinary

 
Musculoskeletal

 
Neurological

 
Psychiatric

 
Lab Tests (lists any tests ordered and status of the test, if a rapid test was done at the office, list the results)

 
Special Tests (List any imaging study or special test ordered and status of the test, if the result is available, write the result)

 
 Diagnosis
 Differential Diagnoses with ICD 10 codes (these are Dx you considered, but then ruled out)

· 1-

· 2-

· 3-

Diagnosis with ICD 10 Code

CPT Code/Office visit code:

 

 
Plan/Therapeutics
· Plan:

· Further testing

· Medication

· Education

· Non-medication treatments

· Follow Up

· Referral

· When to seek emergency care

 

 
 Evaluation of patient encounter

Document your level of interaction with the patient.

Weaknesses:

Strengths:

Reflection:

References: